Abstract
A) Adult Inborn Errors of Metabolism (001 to 037)
001 - Clinical Presentation of Late-Onset Multiple Acyl-CoA Dehydrogenase Deficiency
Beena Devanapalli1, Michel Tchan2, and Kevin Carpenter1
1Sydney Children’s Hospital Network, Westmead, Australia
2Genetic Medicine, Westmead Hospital, Westmead, Australia
Multiple acyl-CoA dehydrogenase deficiency (MADD) is an inborn error of metabolism affecting the catabolism of branched chain amino acids, lysine and tryptophan, as well as β oxidation of fatty acids. It results in impaired ATP synthesis, excessive lipid accumulation, and impaired gluconeogenesis. The condition arises from defects in either the electron transfer flavoprotein (ETF A/B gene) or ETF-ubiquinone oxidoreductase (ETFDH gene). Three phenotypes are recognized: neonatal onset with congenital anomalies, neonatal onset without congenital anomalies, and late onset. Late onset form age of presentation is variable, and symptoms range from muscular/cardiac to episodic vomiting. Diagnosis is based on urinary organic acid and plasma acylcarnitine profile. We describe a male presenting at 26 years of age with a vasculitic rash which worsened with fluctuating consciousness progressing to encephalitis. He had a partially compensated metabolic acidosis (pH 6.92, HCO3 − 6.6, pCO2 32.4), hypoglycemia (3.2 mmol/L), and decreased lactate (<0.3 mmol/L). Plasma acylcarnitine profile collected on day 3 showed low total 10 µmol/L (RR 21-70) and free 2 µmol/L (RR 13-56) carnitine with significant elevations in C5 0.94 µmol/L (RR <0.28 µmol/L) and C5 DC 1.55 µmol/L (RR <0.34 µmol/L). The pattern was suggestive of MADD; however, urine metabolic screen showed decreased glycine, but no markers of a fatty acid oxidation defect. Following treatment with IV carnitine, β-hydroxybutyrate, CoQ, riboflavin and glycine, total (52 µmol/L) and free (25 µmol/L) carnitine normalized, but medium-chain species showed significant elevations C5 2.36 µmol/L, C5 DC 4.10 µmol/L, C6 0.58 µmol/L (RR <0.13 µmol/L), C8 2.80 µmol/L (RR <0.24 µmol/L), C10 4.78 µmol/L (RR <0.40 µmol/L). During this period, the patient also suffered subcortical hemorrhage requiring drainage, fluctuating GCS, renal failure requiring dialysis, and collapsed lung. His condition improved significantly both biochemically and clinically, and he was able to be discharged on day 24 and remains on the medications above and a low-fat diet. Mutation testing results for ETF A/B and DH are pending. The precipitating factors are unclear, but the underlying infection producing the vasculitic rash is suspected to be the trigger.
002 - Characterization of SLC6A8 Mutations in Creatine Transporter Deficiency (CTD)
Courtney Alexander1 and Alex Bruchey2
1University of Texas, Lumos Pharma, Austin, TX, USA
2Lumos Pharma, Austin, TX, USA
SLC6A8 gene mutations impair the transport of creatine into cells, and the effects of creatine deficiency are most debilitating in organs and tissues that require rapid high energy production, especially the brain. Creatine transporter deficiency (CTD) is an X-linked disease, thus males often have more severe phenotype than females. Patients with CTD have decreased or absent brain creatine, as measured by MRS, and increased creatine–creatinine ratio in urine. They present with mild to severe intellectual disability with prominent delays in speech and language development. CTD patients can also experience seizures with a delay in the development of motor skills. The prevalence of CTD is unknown; however, more than 250 affected individuals have been identified. Based predominantly on mutation data in the Leiden Open Variation Database (LOVD), we conducted a systematic search of studies in the human gene mutation database (HGMD) and PubMed, in which the pathogenicity of SLC6A8 mutation was known. Objective was to compile a current catalogue of pathogenic mutations in the SLC6A8 gene and correlate genetic information with symptomatic profile, thus advancing our investigation into potential biomarkers of CTD. From our search, we created an SLC6A8 gene pathogenic mutation database consisting of the location of the mutation, cDNA nucleotide substitution, corresponding protein change, type of mutation, and an assigned clinical phenotype. The most frequent types of mutations were nonsense (43), missense (41), and deletion (32), with 8 distinct de novo mutations. It is estimated that approximately 30% of SLC6A8 mutations are de novo mutations. The most reported clinical phenotypes were intellectual disability and mild intellectual disability. Mutations clustered around exons 6 through 12, with exon 9 having the most (16), next to exon 6 (14), exon 12 (12), and exons 7 and 8 with an equal number of mutations (10 each). SLC6 transporter family has the substrate binding site located at the core of the transporter, with the inner ring that forms the substrate binding site coded by exons 1, 3, 6, and 8. We strongly encourage researchers and clinicians to submit SLC6A8 gene variants to LOVD, as this database is the most expansive published database of pathogenic and nonpathogenic mutations of this gene and is a valuable resource for genetic counselors.
003 - In Vivo Models for Qatari Specific Classical Homocystinuria as Basis for Development of Novel Therapies
Gheyath Nasrallah1, Hesham Ismail1, Nader Aldewik2, Johannes HäBerle3, Beat Thöny3, Warren Kruger4, Henk Blom5, and Tawfeg Ben-Omran2
1Qatar University, Doha, Qatar
2Clinical and Metabolic Genetics, Department of Pediatrics, Hamad Medical Corporation, Doha, Qatar
3University Children’s Hospital and Children’s Research Center, Zurich, Switzerland
4Cancer Biology Program, Fox Chase Cancer Center, Philadelphia, PA, USA
5Laboratory of Clinical Biochemistry and Metabolism, University Medical Centre Freiburg, Freiburg, Germany
004 - Long-Term Follow-Up in Women With X-Linked Adrenoleukodystrophy: A Prospective Cohort Study
Irene Huffnagel1, Björn Van Geel2, Bwee Tien Poll-The1, Stephan Kemp1, and Marc Engelen1
1Academic Medical Centre, Amsterdam, the Netherlands
2Medical Centre Alkmaar, Alkmaar, the Netherlands
005 - Hemodynamic and Catecholaminergic Response to Stress in Adult Patients With Phenylketonuria
Csaba Sumánszki1, Fanni Palásti1, Krisztián Kovács2, Gellért Karvaly2, Erika Kiss3, Erika Simon3, Atilla Patócs4, and Péter Reismann5
1Second Department of Medicine, Semmelweis University, Budapest, Budapest, Hungary
2Department of Laboratory Medicine, Semmelweis University, Budapest, Hungary
3First Department of Pediatrics, Semmelweis University, Budapest, Hungary
4Molecular Medicine Research Group, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
5Second Department of Medicine, Semmelweis University, Budapest, Hungary
006 - Assessment of the Effect of Once Daily Nitisinone therapy on 24-h Urinary Metadrenalines and 5-Hydroxyindole Acetic Acid Excretion
Lakshminarayan Ranganath1, Andrew Davison1, Anna Milan1, Andrew Hughes1, Milad Khedr1, Brendon Norman2, and James Gallagher2
1Royal Liverpool University Hospital, Liverpool, United Kingdom
2University of Liverpool, Liverpool, United Kingdom
007 - The Severe Morbidity of Iconic Disease Alkaptonuria (AKU): Data From the United Kingdom National Alkaptonuria Center
Lakshminarayan Ranganath1, Milad Khedr1, and James Gallagher2
1Royal Liverpool University Hospital, Liverpool, United Kingdom
2University of Liverpool, Liverpool, United Kingdom
Alkaptonuria (AKU) is a rare genetic deficiency of homogentisate dioxygenase (HGD), characterized by high circulating homogentisic acid (HGA), some of which is deposited in connective tissue as a pigment, a process termed ochronosis. AKU being a genetic disease is present from birth but in the pediatric age group is mostly asymptomatic and considered a chemical curiosity. Data on 50 patients (20 female: 53.1+14.9 years; 30 male: 47+13.9 years) with AKU visiting the United Kingdom National Alkaptonuria Centre in Liverpool for assessment is presented. Some of the morbidity is due to HGA itself in the form of lithiasis with prevalence of renal and prostate stones of 26% and 60%, respectively. Osteopenia is present in 64%. There were 37 fractures in the cohort. There were 28 ruptures mainly of muscle and tendons. 58% had aortic valve disease. 18 of the 50 had joint replacements (63 in all). We highlight the considerable morbidity to emphasize that AKU is not a benign disease.
008 - Acute Manifestation of Classical Homocystinuria After Major Trauma in an Adult Patient Requiring Parenteral Nutrition
Christel Tran1, Luisa Bonafé1, Jean-Marc Nuoffer2, Julie Rieger1, and Mette Berger1
1Lausanne University Hospital, Lausanne, Switzerland
2University Institute of Clinical Chemistry, Bern, Switzerland
009 - A Case Report on a MPS II Patients With Parkinson-Like Symptoms
Jose Maria Satizabal Soto1, Adalberto Sanchez1, and Lina Johanna Moreno Giraldo2
1Universidad Del Valle, Cali, Colombia
2Universidad Del Valle, Universidad Santiago de Cali -, Cali, Colombia
Mucopolysaccharidosis type II, MPS II or Hunteŕs syndrome, is a chronic and progressive disease related to a dysfunction on lysosomal activity. The molecular manifestation of this disease is a deficiency on iduronate-2 sulfatase enzyme. This deficiency interferes on recycling and metabolic pathways of mucopolysaccharides or glycosaminoglycans into lysosomes. These events lead to a multisystemic organ dysfunction. More than 300 mutations have been reported on the IDS gene as a cause for this disorder. MPSs are sometimes related to other complex diseases like neurological disorders. Tubulinophaties are a heterogeneous group of conditions related to a large spectrum of malformations of cortical development. Recent studies have reported critical effects of tubulins and microtubule-associated proteins involvement in malformations of cortical development. A male patient showing globose abdomen, splenomegaly, dysmorphic facial features, tremors and signs related to Parkinson’s disease, no perinatal or significant findings in the family history, normal karyotype, and radiographic findings of long bones and signs of disostosis. Exome sequencing was performed on the iIIumina platform and single-nucleotide variants were found on IDS and TUBB3 genes. The variant for IDS was located on position X:148579779 (c566-567 T>TT) leading a truncated protein product. TUBB3 variant was located on position 16:89986117 (C>T), and identified as rs1805007 with a pathogenic effect. Literature reports support a low prevalence of tubulinopathies related to TUBB3. In conclusion, it is important to identify the genotype by exome sequencing in patients with MPS manifestations in order to avoid misinterpretations and wrong diagnosis.
010 - Diagnosis of Gaucher Type 1 Disease Among Adult Patients With Splenomegaly, Avascular Osteonecrosis and/or Hip Replacement of Unknown Cause: Preliminary Results
Jordi Pérez-López1, Marc Moltó-Abad1, Adolfo Díez-Pérez2, Ana Arévalo-Gómez3, Cecilia Muñoz-Delgado4, Elena Patera5, Emiliana Eusebio-Ponce6, Laura Maglio7, Natalia Costa8, Pablo Demelo-Rodríguez4, Rachida Soultana9, Sabina Herrera2, Silvana Novelli10, and Xavier Solanich11
1Inborn Errors of Metabolism Unit, Internal Medicine Department, Hospital Vall Hebron, Barcelona, Spain
2Internal Medicine, Hospital Del Mar, Barcelona, Spain
3Internal Medicine Department, Hospital Juan Canalejo, La Coruña, Spain
4Internal Medicine Department, Hospital Gregorio Marañón, Madrid, Spain
5Internal Medicine Department, Hospital de Calella, Barcelona, Spain
6Hematology Department, Hospital Rio Hortega, Valladolid, Spain
7Hematology Department, Hospital Arnau de Vilanova, Lleida, Spain
8Internal Medicine Department, Hospital de Can Misses, Ibiza, Spain
9Hematology Department, Hospital de Mataró, Barcelona, Spain
10Hematology Department, Hospital de Sant Pau, Barcelona, Spain
11Internal Medicine Department, Hospital de Bellvitge, Barcelona, Spain
011 - Three-Year Experience of Pediatric Metabolic Physicians With Adult Inpatient Consultations
Yilmaz Yildiz, Emine Goksoy, Berrak Bilginer Gurbuz, Ali Dursun, Ayşegül Tokatli, Turgay Coskun, and Serap Sivri
Hacettepe University, Ankara, Turkey
Physicians specialized in inborn errors of metabolism (IEMs) are a small and growing group. In many regions, as in Turkey, physicians caring for adults have not specialized in metabolic diseases, and pediatric metabolic physicians continue to care for patients of all ages. With this study, we aimed to evaluate the spectrum of adult inpatient consultations to the pediatric metabolic department at a major metabolic center in Turkey retrospectively. Inpatient consultations to the pediatric metabolic department regarding patients over 18 years of age during the 2014-2016 study period were included. A total of 48 patients were consulted. 14 of them already had an established diagnosis of an IEM, 2 of which were consulted before child labor and 4 before surgery. The remaining 34 (age 19-63) were consulted for suspicion of an IEM (21 consults in 2016). Majority of consultations were from the departments of neurology or internal medicine and none from psychiatry. Among these 34 patients, 21 had neurological findings, followed by 12 patients with musculoskeletal, 8 with nephrological, and fewer with other findings. A definite diagnosis of an IEM was reached in 11 of 34 patients (32.3%): 2 were diagnosed with L-2-hydroxyglutaric aciduria, and 1 each with metachromatic leukodystrophy, Fabry disease, Hunter syndrome, mitochondrial neurogastrointestinal encephalopathy, X-linked adrenoleukodystrophy, Leber’s hereditary optic neuropathy, classical homocystinuria, carnitine palmitoyl transferase-II deficiency, and cerebrotendinous xanthomatosis. Specific metabolic treatment was started in 10 patients. It is well-established that IEMs in adults mainly present with neuropsychiatric problems. Scarcity of psychiatric findings and consultations from the psychiatry clinic may suggest that IEMs with solely psychiatric presentations may have been missed. The fact that a third of adults consulted for suspicion of an IEM received a definite diagnosis reveals that consultations to pediatric metabolic physicians regarding adults are extremely relevant. The diagnostic yield may have been even higher if metabolomic or genomic approaches could have been used. Workshops by the pediatric metabolic department may have raised awareness of IEMs, increasing the number of consultations over the years. IEMs in adults is a challenging issue, which pediatric metabolic physicians must try to tend to until physicians caring for adults in their region specialize in this ever-growing field.
012 - A Case Report of Recurrent Urolithiasis Owing to Cystinuria Diagnosed in Adulthood
Carlos Alberto Garzón Bejarano1, Orietta Ivonne Beltrán2, and Adriana Ramírez3
1Grupo de Biogenética & Bioderecho. Facultad de Medicina, Universidad Militar Nueva Granada, Bogotá, Bogotá DC, Colombia
2Departamento de Genética, Organización Sanitas Internacional, Bogotá, Colombia, Bogota DC, Colombia
3Laboratorio Clínico Organización Sanitas Internacional, Bogotá, Colombia, Bogotá DC, Colombia
013 - Sustained Radiographic and Functional Improvements With Asfotase Alfa Treatment for up to 7 Years in Children With Hypophosphatasia
Michael Whyte1, Cheryl Rockman-Greenberg2, Scott Moseley3, Andrew Denker3, Eric Watsky3, and William Mcalister4
1Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals For Children, St. Louis, MO, USA
2Univ of Manitoba Max Rady College of Medicine and Children’s Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
3Alexion Pharmaceuticals, Inc., New Haven, CT, USA
4Washington University School of Medicine, Mallinckrodt Institute of Radiology, St. Louis, MO, USA
Children with hypophosphatasia (HPP) treated with asfotase alfa in a Phase 2 study (NCT00952484) and its open-label extension (NCT01203826) experienced significant improvements in skeletal mineralization and physical function that were sustained through 5 y of treatment [1]. Results through 7 years of treatment are reported here. Children with HPP aged 6 to 12 y at baseline were initially randomized to receive asfotase alfa 6 or 9 mg/kg/wk SC for 6 months and continued in an open-label extension where they received asfotase alfa 3 mg/kg/wk SC, later increased to 6 mg/kg/wk. Radiographs of hands/wrists and knees were assessed using the Radiographic Global Impression of Change (RGI-C) scale and Rickets Severity Scale (RSS). Additional outcome measures included growth; functional ability/disability (6-Minute Walk Test [6MWT]; Bruininks-Oseretsky Test of Motor Proficiency, 2nd Edition [BOT-2] Strength and Agility Composite Standard Score; Child Health Assessment Questionnaire Disability Index [CHAQ-DI]); and safety. Data are reported as median (minimum, maximum) change from baseline, except for RGI-C which is a measurement of change from baseline (range: −3 [severe worsening] to +3 [complete/near complete healing]). All 12 children who entered the extension phase received asfotase alfa for up to 7 years’ total exposure. Improvements in HPP-related skeletal manifestations were documented and sustained through end of study (final median [min, max] RGI-C score: 2.8 [2.0, 3.0], P = .0005; RSS score: −2.8 [−5.0, −0.5], statistical testing not performed). Improved growth (height Z-score: 0.8 [−0.2, 1.9], P = .0007; weight Z-score: 1.1 [0.3, 3.4], P = .0004) and function (% predicted 6MWT: 26.7 [1.1, 56.1], P = .0006; BOT-2 Strength and Agility score: 23.0 [7.0, 30.0], P < .0001; and CHAQ-DI: −0.9 [−1.8, 0], P = .0004) were also sustained through end of study. All patients had mild to moderate injection site reactions (e.g., erythema, macule, lipohypertrophy); 1 event of injection site atrophy was assessed as severe. No serious adverse events, including deaths, were reported. Improvements in HPP-related skeletal manifestations, growth, and functional ability with asfotase alfa in children with HPP persisted at 7 years of treatment. Treatment was generally well tolerated. [Data previously presented at the International Conference of Children’s Bone Health, June 10–13, 2017.]
1. Whyte MP, Madson KL, Philips D, et al. Asfotase alfa therapy for children with hypophosphatasia. JCI Insight. 2016;1(9):e85971.
014 - Biochemical and Physical Function Outcomes At 5 Years of Treatment With Asfotase Alfa in Adolescents and Adults With Hypophosphatasia: Phase 2 Study Results
Priya S. Kishnani1, Cheryl Rockman-Greenberg2, Andrew Denker3, Scott Moseley3, Eric Watsky3, and Michael Whyte4
1Duke University Medical Center, Durham, NC, USA
2University of Manitoba Max Rady College of Medicine and Children’s Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
3Alexion Pharmaceuticals, Inc., New Haven, CT, USA
4Center for Metabolic Bone Disease and Molecular Research, Shriners Hospitals for Children, St. Louis, MO, USA
This phase 2, open-label, randomized, dose-ranging study (NCT01163149) evaluated the safety and efficacy of 5 years of treatment with asfotase alfa in adolescents and adults with hypophosphatasia (HPP). Treatment with asfotase alfa 0.3 or 0.5 mg/kg/day SC was compared with no treatment (control) for 6 months in patients aged 13 to 66 years. All patients (treatment and control) then received asfotase alfa 0.5 mg/kg/day SC, which was increased after 6 to 12mo to 1 mg/kg 6x/wk (lowest effective dose). The primary safety outcome was tolerability. Coprimary efficacy outcomes were median change at 6 months in plasma inorganic pyrophosphate (PPi) and pyridoxal-5’-phosphate (PLP) levels. Other measures included 6 Minute Walk Test (6MWT) and Bruininks-Oseretsky Test of Motor Proficiency, 2nd Edition (BOT-2). Data from treatment groups were pooled and reported as median (min, max). Nineteen patients were randomized (6 aged 13-<18 y; 13 aged ≥18 years); 15/19 (79%) completed 5 years of treatment; 1 withdrew due to injection-site hypersensitivity and anaphylactoid reaction (1 episode each). No deaths occurred. The most common treatment-emergent adverse events were injection-site reactions. Decreases in PPi were numerically greater and decreases in PLP were statistically significant at 6 months of asfotase alfa treatment (n = 13) vs. controls (n = 6): PPi, −2.2 μM (−4.4, 0.3) vs. −0.2 (−6.8, 1.1; P = .0715); PLP, −255 ng/mL (−1467, −17) vs. 11 (−374, 346; P = .0285). Decreases were sustained at 5 y (n = 16): PPi, −3.0 μM (−5.2, 7.8); PLP, −284 ng/mL (−1580, −25). 6MWT distance walked improved from 355 m (10, 620; n = 19) before treatment to 450 m (280, 707; n = 13) at 5 y of asfotase alfa treatment, increasing from 76% predicted (42, 101; n = 15) to 88% predicted (62, 137; n = 11). BOT-2 Running Speed and Agility total point score was 6.5 (0, 39; n = 16) before treatment and improved by 4.0 (−5, 18; n = 11) at 5 years. BOT-2 Strength total point score was 13.5 (0, 33; n = 18) before treatment and improved by 3.5 (−9, 9; n = 12) at 5 years. Asfotase alfa was generally well tolerated. The coprimary outcome measure (changes in PPi and PLP at 6 months) was not met. Asfotase alfa significantly decreased circulating PPi and PLP levels and improved physical function in adolescents and adults with HPP through 5 years’ of treatment. [Data previously presented at: 44th European Calcified Tissue Society (ECTS), May 13-16, 2017; International Conference of Children’s Bone Health (ICCBH), June 10-13, 2017.]
015 - DOORS: A Dysmorphic and Syndromic Sensorineural Deafness Caused by 2-Ketoglutarate Dehydrogenase Deficiency
Holguer Santiago Estrella Benavides1, Débora Romeo Bertola2, Cristina Núñez Vaca2, Rachel Sayuri Honjo2, Guilherme Lopes Yamamoto2, José Ricardo Magliocco Ceroni2, Sofía Ortiz Saldaña2, Diana Salazar Bermeo2, Gustavo Marquezani Spolador2, Chong Ae Kim2, Luiz Nunez de Oliveira3, Ricardo Ferreira Bento4, and Patrícia Paula Santoro4
1Hospital das Clínicas da Univerisdade de Sao Paulo, São Paulo, Brazil
2Genetics Unit of Instituto da Criança do Hospital das Clínicas da Universidade do São Paulo, São Paulo, Brazil
3Radiology Department of Instituto da Criança do Hospital das Clínicas da Universidade, São Paulo, Brazil
4Otorhinolaryngology Department, Hospital das Clínicas, University of São Paulo Faculty of Medicine, São Paulo, Brazil
DOORS is an acronym for deafness, onychodystrophy, osteodystrophy, mental retardation, and seizures. The syndrome has been classified into 2 types: the first one characterized by organic acid abnormalities, early seizures, progressive blindness, deafness, and early death in some cases; type 2 is not accompanied with organic acid abnormalities and is associated with mild neurological involvement. Nevertheless, the literature review suggests that the division is not clear. DOORS (MIM 220500) is caused by homozygous or compound heterozygous mutation in the TBC1D24 gene on chromosome region 16p13, leading to a deficiency of 2-ketoglutarate dehydrogenase, which is part of the of the 2-oxoglutarate dehydrogenase complex. This is located within the mitochondrial matrix and converts 2-oxoglutarate to succinylCoA and CO2. Case report: A 10-year-old boy was referred to the Genetics Unit due to sensorineural hearing loss, delayed psychomotor development, short stature, and mild dysmorphisms. The patient is the only child of a consanguineous couple. After an uneventful pregnancy, the patient was born at 36 weeks, presenting neonatal hypoglycemia. Newborn hearing screening was abnormal bilaterally. At the age of 3 months, sensorineural bilateral deafness was diagnosed, and the patient underwent cochlear implant surgery. The patient never had seizures. At physical examination at 8 years of age, the patient had proportionate short stature, mild facial dysmorphism, onychodystrophy, and short fingernails. The ophthalmologic examination revealed pale optic nerve and astigmatism (>7 diopters). The neurological examination revealed a mild degree of ataxia and hyporeflexia of inferior limbs. Abdominal ultrasound and echocardiography were normal. The X-rays of hands and feet revealed global hypoplasia of the terminal phalanges. Chromosomal analysis revealed a normal male karyotype. Considering the clinical and imaging findings, the hypothesis of DOORS was considered. The urinary organic acids analysis showed an increase of 2-ketoglutarate acid. This case exemplifies an inborn error of metabolism presenting as syndromic sensorineural deafness through the disturbance of 2-ketoglutarate dehydrogenase complex activity. DOORS is also one of the dysmorphic syndromes with a demonstrable biochemical abnormality. The analysis of organic acids may be a diagnostic clue and supportive of a clinical diagnosis if molecular analysis is not available.
016 - Blood Spot Testing for (Late Onset) Pompe Disease
Julia Dobbins, Tim Pyragius, Kristian Brion, Sharon Chin, Melissa Gurner, Janina Pacyna, Samantha Stark, and Janice Fletcher
Sa Pathology, Adelaide, Australia
017 - Pyruvate Dehydrogenase E1-Alpha Deficiency, A Case Report
Felix-Julian Campos-Garcia1, Eugenia-Dolores Ruiz-Cruz2, Claudia Moreno-Graciano3, Luz-Del-Alba Herrera-Perez3, and Patricia Martinez-Cruz4
1Star Medica, Merida, Mexico
2Instituto Mexicano Del Seguro Social, Umae, Mérida, Mexico
3Tamizaje Plus Sa de Cv (Tamizmas), Yucatán, México, Mérida, Mexico
4Tamizaje Plus Sa de Cv (Tamizmas), Yucatán, México, Merida, Mexico
018 - The First Experience of Successful Treatment of Adult Patients With Late Diagnosis of BH4-Dependent Hyperphenylalaninemia
Valentina Larionova1, Elena Koroleva2, Sergey Dement3, Kamal Isaev4, Galina Mazo5, and Viacheslav Ironosov4
1North-Western State Medical University Named After I.I. Mechnikov, Saint-Petersburg, Russia
2North-West Center of Evidence-Based Medicine, Saint-Petersburg, Russia
3International Clinic, Saint-Petersburg, Russia
4Federal State Budgetary Research Institution, Saint-Petersburg, Russia
5Saint-Petersburg Phychoneurological Scientific Research Institute Named by Bechterev V.M, Saint-Petersburg, Russia
Two female siblings, 31 yo and 27 yo, were presented with mild hyperphenylalaninemia diagnosed at their first year of life but noncurable by phenylalanine-free diet. Both patients had progressing symptoms such as seizures, dystonia, hyper salivation, depression, and insomnia. One of them displayed a light pigmentation. At the puberty, a severe deterioration of their condition occurred as abnormal movement, impaired tone and posture, hypertonia of extremities, and drug-resistant seizures. Based on these clinical signs and symptoms, BH4 deficiency was suspected and treatment with “Nakom” was administrated at the patients ages of 26 yo and 22 yo followed by a slight positive effect. Molecular genetic testing of PTS gene showed two mutations (pThr106Met and p. Asn72Lys). Despite initial low blood phenylalanine levels (290.6 and 286.8 mkg/mL, correspondingly), the patients (aged 24 yo and 28 yo) were referred to 3-day BH4 loading test with a commercially available formulation of BH4 (sapropterin dihydrochloride, Kuvan) at the dose of 20 mg/kg. BH4 loading test detected BH4 dependence: decrease in phenylalanine level by around 90.0% in both patients after eight hours of implementation. Aiming determination an effective dose of Kuvan, we tested parameters of neurotransmitters (including blood levels of 5-OH-tryptophan, serotonin and tryptophan, daily urine levels of vanillylmandelic acid (VMA), homovanillic acid (HVA, and 5-hydroxyindoleacetic acid (5-HIAA)) after administration of 5 mg/kg and of 10 mg/kg, each course lasted 5 days Normalization of all metabolites occurred at the dose of 10mg/kg which had been using for the further treatment. Upon 1 year of treatment, MRT of the brain showed positive changes. Currently, the elder sister is married, she was taking Kuvan throughout her uneventful pregnancy and gave birth to a healthy baby.
019 - Evaluation of Respiratory and Motor Functions in Patients With Late-Onset Pompe Disease in Slovakia
Katarína Juríčková1, Anna Hlavata1, and Vladimír Hupka2
1Department of Pediatrics University Children’s Hospital, Bratislava, Slovakia
2The National Institute of Cardiovascular Diseases, Bratislava, Slovakia
020 - Early and Prodromal Neurodegenerative Markers in Adult PKU Patients
Andrea Pilotto1, Carl Zipser2, Edytha Charyasz3, Peter Freisinger4, Klaus Scheffler3, Nenad Blau5, Georg F. Hoffmann5, Eva Schaeffer6, Inga Liepelt-Scarfone7, Walter Maetzler6, Alessandro Padovani8, Friedrich Karl Trefz5, and Daniela Berg6
1Department of Neurodegeneration, University of Tübingen and Neurology Unit, University of Brescia, Tübingen, Germany
2Department of Neurology and Stroke, Hertie Institute for Clinical Brain Research, Tübingen, Germany
3Department of Biomedical Magnetic Resonance, University of Tübingen, Tübingen, Germany
4Department of Pediatrics, Reutlingen Hospital, Reutlingen, Germany
5Centre For Pediatric and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
6Department of Neurology, University-Hospital-Schleswig-Holstein, University of Kiel, Kiel, Germany
7University of Tübingen, Tuebingen, Germany
8University of Brescia, Brescia, Italy
021 - Oligosymptomatic Cerebrotendinous Xantomatosis (CTX): A Case Report
Marina Szlago1, Ricardo Solari2, and Ramiro Garcia Valdivieso3
1Consultorio Errores Congenitos Del Metabolismo, Caba, Argentina
2Jefe de Servicio Ortopedia Y Traumatologia. Hosp. B. Rivadavia., Caba, Argentina
3Servicio Ortopedia Y Traumatologia. Hosp. B. Rivadavia., Caba, Argentina
Cerebrotendinous Xanthomatosis (Mc Kusick 213700) is an autosomal recessive disorder caused by the deficiency of sterol 27-hydroxilase that results in reduced production of bile acids, predominantly chenodeoxycholic acid (CDCA), and in the increased formation of intermediates such as cholestanol and 27-carbon bile alcohols. The classical clinical presentations of CTX are Achilles tendon xanthomas, cataracts, chronic diarrhea, and neurologic dysfunction. CTX is treatable with CDCA, which inhibits abnormal bile-acid synthesis and slows the progression of the disease. We report a CTX oligosymptomatic patient whose diagnosis was suspected by an orthopedic traumatology specialist. MIV, 23-year-old female was referred to IEM Unit by her orthopedic traumatologist because of CTX suspicion. At the age of 14, she had right ankle pain when walking and was diagnosed as having sprain. After 15 days of rest, contralateral ankle pain began and a new sprain was diagnosed. Bilateral plaster was indicated with no improvement. After a new evaluation, Achilles tendon biopsy was performed. She received no treatment. Through the following years, she developed bilateral Achilles tumors that impaired her for wearing shoes, feet movements, and gait. Ankle MRI performed at 23 years old revealed thickening of the Achilles tendon compatible with xanthomas. Brain MRI, ophthalmologic, neurologic, and cardiology evaluations were normal. Surgery treatment was indicated. Orthopedic traumatologist suspected CTX. Histopathology of the tumor revealed fibroxanthoma. Urinary bile acid profile was diagnostic for CTX. Genetic test revealed homozygous for c.1183C>T (p.Arg395Cys). Chenodesoxycholic acid has been indicated. We emphasize the importance of the suspicion by the specialist that allowed the diagnosis and the indication of the specific treatment aiming at avoiding the progressive deterioration characteristic of this disease.
022 - Quality of Life of Patients With Lysosomal Storage Disorders in Slovakia
Anna Hlavata1, Katarína Juríčková1, Petra Jungova2, and Miriam Kolníková3
1Department of Pediatrics, University Children’s Hospital, Bratislava, Slovakia
2Institute of Medical Biology, Genetics and Clinical Genetics, Bratislava, Slovakia
3Department of Paediatric Neurology, Bratislava, Slovakia
023 - Hyperoxaluria Type 1 And the Transplant as an Option
Ignacio Zarante1, Lina Mora2, and Angela Paredes1
1Pontificia Universidad Javeriana, Bogotá, Colombia
2Hospital Universitario San Ignacio, Bogotá, Colombia
Primary hyperoxaluria type 1 (PH1) is an autosomal recessive disorder of glyoxylate metabolism, characterized by an excess of oxalate, secondary to a deficiency of glyoxylate aminotransferase (AGT). Individuals have a variable clinical presentation from recurrent nephrolithiasis, nephrocalcinosis, to renal terminal disease with systemic oxalosis. Liver or liver/renal transplantation is an acceptable option for disease therapy or perhaps cure. We present a case report of primary hyperoxaluria type 1 and the importance of an adequate study of related donor in patients with the end-stage renal disease.
024 - CSF Biogenic Amines Depletion and Brain Atrophy in Adult PKU Patients
Andrea Pilotto1, Nenad Blau2, Edytha Charyasz3, Claudia Schulte4, Christian Deuschl4, Carl Zipser5, David Piel6, Peter Freisinger7, Gwendolyn Gramer2, Stefan Koelker2, Dorothea Haas2, Peter Burgard8, Peter Nawroth8, Georg F. Hoffmann2, Klaus Scheffler3, Daniela Berg9, and Friedrich Karl Trefz2
1University of Tübingen, Tuebingen, Germany
2Centre For Pediatric and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
3Department of Biomedical Magnetic Resonance, University of Tübingen, Tübingen, Germany
4Department of Neurodegeneration, Hertie Institute of Clinical Brain Research, University of Tübingen, Tübingen, Germany
5Department of Neurology, Hertie Institute of Clinical Brain Research, University of Tübingen, Tübingen, Germany
6Department of Endocrinology, Internal Medicine I, University of Heidelberg, Heidelberg, Germany
7Pediatrics, Reutlingen Hospital, Reutlingen, Reutlingen, Germany
8Department of Pediatrics, University of Heidelberg, Heidelberg, Germany
9Neurology Unit, University of Tübingen and Neurology Unit, University of Kiel, Kiel, Germany
025 - Successful Management of Pregnancies in Patients With Inherited Disorders of Ketone Body Metabolism
Zuhair Al-Hassnan, Raashda Sulaiman, Maha Al-Nemer, Rubina Khan, Munirah Almasned, and Bedour Handoom
King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
Patients with succinyl-CoA 3-oxoacid CoA transferase (SCOT) deficiency and 3-hydroxy-3 methylglutaryl (HMG)-CoA lyase deficiency are at increased risk of developing metabolic acidosis and hypoglycemia during pregnancy, delivery, and post-partum period. This can be fatal if not treated appropriately. Pregnancy in such patients should be managed in a specialist center by a multidisciplinary team including metabolic physician, high-risk obstetrician, and metabolic dietician. We report two pregnancies in women with SCOT deficiency and HMG-CoA lyase deficiency, which were successfully managed at this tertiary care center. The patient with SCOT deficiency had recurrent ketoacidosis due to severe nausea and vomiting requiring several hospital admissions during pregnancy, while the patient with HMG CoA lyase deficiency remained metabolically stable. Both patients, nevertheless, had normal delivery of live born infants and had uneventful post-partum period.
026 - Partial OTC Deficiency in a Symptomatic Urea Cycle Disease Carrier
Orietta Beltran1, Orietta Ivonne Beltran Casas2, Dora Fonseca3, and Carlos Martín Restrepo3
1Organización Sanitas Internacional & Facultad Medicina, Universidad Militar Nueva Granada, Bogotá, Colombia
2Programa de Errores Innatos Del Metabolismo. Fundación Liga Central Contra Epilepsia, Bogotá, Colombia
3Facultad de Medicina & Genética Molecular de Colombia., Bogotá, Colombia
027 - Brain MRI Characteristics and Scoring in Adult Onset Krabbe Disease
Yann Nadjar1, Louis Cousyn1, Bruno Law Ye2, Delphine Leclercq2, and Nadya Pyatigorskaya2
1Neurology Department, Reference Center for Lysosomal Diseases (Crml), Hôpital Pitié Salpêtrière, Paris, France
2Neuroradiology Department, Hôpital Pitié Salpétrière, Paris, France
028 - Clinical Phenotypes of Adult Onset GM2 Gangliosidosis
Yann Nadjar1, Louis Dufour1, Lisa Saleille1, Catherine Caillaud2, Foudil Lamari3, and Benedicte Heron4
1Neurology Department, Reference Center For Lysosomal Diseases (Crml), Hôpital Pitié Salpêtrière, Paris, France
2Unité Inserm U1151, Université Paris Descartes, Laboratoire de Biochimie Métabolomique Et Protéomique, Paris, France
3Department of Metabolic Biochemistry and Grc 13-Neurometabolism-Upmc Hôpital Pitié-Salpêtrière, Paris, France
4Reference Centre For Lysosomal Diseases (Crml), Neuropediatricstrousseau Hospital, Paris, France
029 - Quality of Life in Adult Patients With Leukodystrophies: The Impact of Perceived Fatigue
João Durães1, Miguel Tábuas-Pereira1, Lúcia Lacerda2, Isabel Alonso3, and Maria do Carmo Macário1
1Neurology Department, Coimbra Hospital and University Centre, Coimbra, Portugal
2Biochemical Genetics Unit, Porto Hospital Centre, Porto, Portugal
3Centre For Predictive and Preventive Genetics, Institute for Cell and Molecular Biology, Porto, Portugal
030 - Phenotypic Heterogeneity in Gaucher disease: Variable Parkinsonism in Patients With the Same Genotype
João Durães1, João Gomes2, Tabita Magalhães Maia2, Joana Vedes3, Lúcia Lacerda4, Dulce Quelhas4, Carla Caseiro4, and Maria do Carmo Macário1
1Neurology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
2Hematology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
3Internal Medicine Department, Unidade Local de Saúde da Guarda, Guarda, Portugal
4Institute of Medical Genetics Jacinto Magalhães, Centro Hospitalar do Porto, Porto, Portugal
031 - Quality of Life in Adult Portuguese Patients With Mitochondrial Diseases: Initial Validation of an Assessment Instrument
João Durães1, Pedro Faustino2, Bárbara Oliveiros2, Paula Garcia3, Luísa Diogo3, Manuela Grazina4, and Maria do Carmo Macário1
1Neurology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
2Faculty of Medicine, Universidade de Coimbra, Coimbra, Portugal
3Metabolic Unit, Centre for Child Development, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
4Biochemical Genetics Laboratory, Centre for Neuroscience and Cell Biology, Coimbra, Portugal
032 - Two Adult Brothers With Mental Retardation of Metabolic Origin, Suspected by the Magnetic Resonance Imaging (MRI)
Pilar Peredo, Juan Francisco Cabello, Carolina Arias, Castro Chaves, Valerie Hamilton, Alicia de La Parra, and Veronica Cornejo
Inta, Santiago, Chile
033 - Pregnancy Unmasking Sialidosis Type I
Rayana Maia, Alexandre Felício de Campos, Thereza Cavalcanti, and Charles Lourenço
Hospital das Clínicas de Ribeirão Preto, Usp, Ribeirão Preto, SP, Brazil
034 - Adult Onset Adrenomyeloneuropathy With Delayed Diagnosis
Pilar Peredo, Carolina Arias, and Juan Francisco Cabello
Inta, Santiago, Chile
035 - Glucose Transporter Type 1 Deficiency Syndrome: Report of a 30-Year-Old Patient With Atypical Clinical Presentation of Spastic Paraparesis and Ataxia
Carolina Souza1, Flippo Vairo1, Manuela Baldo1, Cristina Bittar2, and Jonas Saute1
1Medical Genetic Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, RS, Brazil
2Hematology Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, RS, Brazil
The phenotypic spectrum of glucose transporter type 1 deficiency syndrome (Glut1) is now known to be a continuum that includes the classic phenotype as well as dystonia 9, dystonia 18, atypical childhood absence epilepsy, myoclonic astatic epilepsy, and paroxysmal nonepileptic findings, such as intermittent ataxia, choreoathetosis, dystonia, and alternating hemiplegia. We aim to present an interesting case regarding a patient that was referred to a Medical Genetics clinic at the age of 11 years due to gait imbalance and seizures started at 2 years of age and controlled since then. Until the age 29, he was submitted to an unsuccessful extensive metabolic and genetic evaluation. Due to megaloblastic anemia, proteinuria and low vitamin B12 levels, he has been treated as a patient with transcobalamin defect, with improvement in the laboratory findings, although the movement disorder characterized by ataxia, spastic paraplegia, and dystonia worsened with time. In order to define the molecular diagnosis, the patient underwent to a multigene NGS panel focused on treatable inborn errors of metabolism, which detected a heterozygous variant in SLC2A1. After the genetic confirmation of GLUT1 deficiency, the past medical charts were reviewed and a spinal tap, done when the patient was 2 years old, showed significant decrease in the glucose levels (23 mg/dL). Interestingly, this finding was not considered relevant in the past. Nowadays, at 30 years of age, the patient has dystonic movements, spasticity, mild cognitive decline, and is wheel chaired. Soon, he will start on a ketogenic diet. Our case report shows an uncommon nonepileptic manifestation of GLUT1 deficiency, presented in less than 10% of the affected individuals. The patient has a milder phenotype, characterized by paroxysmal dyskinesia including intermittent ataxia, choreoathetosis, dystonia, and alternating hemiplegia. We think that it raises the awareness of an interesting inborn error of metabolism that can present with atypical symptoms in adults and should be included in the differential diagnosis of movement disorders.
036 - Globotriaosylsphingosine (Lyso-Gb3) as a Biomarker for Cardiac Variant (p.N215 S) Fabry disease
Fahad Alharbi
PSMMC, Riyadh, Saudi Arabia
037 - From Children to Parents (reverse genetics): CBS deficiency, a “Miss” and Heterogeneous Disease
Ida V D Schwartz
Porto Alegre, RS, Brazil
A newborn female (patient A) was sent to genetic evaluation due to polydactyly. She was the only child of a nonconsanguineous couple. The prenatal period was uneventful. Eventually, his father was also found to present polydactyly. The mother (patient B), 20 years old, was diagnosed as having Marfan syndrome at childhood (lens dislocation, high stature, and normal neuromotor development); she had 3 siblings: a twin sister who died at an early age due to anencephaly, a brother who died at 13 yo due to “heart problems,” and an older sister presenting psychiatric problems and history of thrombosis (patient C). Metabolic investigation confirmed the diagnosis of Classical Homocystinuria (HCU) in patients B and C. Those cases illustrate the natural history of late-diagnosed HCU patients, and the heterogeneity and the lack of awareness by health professionals about this disease. Although the pregnancy of patient A was not associated to a bad outcome, HCU untreated patients have a higher risk of complications during this period. Also interesting is that this family was sent to genetic evaluation because of a common congenital malformation occurring in a newborn (a finding not related to HCU), which suggests metabolic adult patients may be at a smaller risk to be at suspicious of having a genetic disease either because of age or because of the absence of severe anatomic abnormalities.
B) Novel Diagnostic/Laboratory Methods (038 to 065)
038 - A Novel Mutation of Idursulfatase gene in a Libyan Child With a Mucopolysaccharidosis Type II
Maryem Ismail
Misurata Central Hospital, Misurata, Libya
039 - Accurate Enzymatic Assays for Distinguishing Affected From Pseudodeficiencies for Diagnosis and Prognosis of Lysosomal Storage Diseases
Michael Gelb
University of Washington, Seattle, WA, USA
040 - The Diagnostic Yield and Novel Genetic Findings by Clinical Exome Sequencing in Highly Consanguineous Middle Eastern Families With Suspected Mendelian Disorders: Experience With 508 Samples
Nader Aldewik1, Howaida Mohd1, Mariam Al-Mureikhi1, Rehab Ali1, Fatma Al-Mesaifri1, Laila Mahmoud1, Noora Shahbeck1, Karen El Akouri1, Mariam Almulla1, Reem Al Sulaiman1, Sara Musa1, Gabriele Richard2, Jane Juusola2, Fowzan Alkuraya3, and Tawfeg Ben-Omran1
1Clinical and Metabolic Genetics, Department of Pediatrics, Hamad Medical Corporation, Doha, Qatar
2Genedx, Gaithersburg, MD, USA
3Developmental Genetics Unit, Department of Genetics, Research Center, King Faisal Specialist Hospital, Riyadh, Saudi Arabia
041 - A Novel Method for Screening of Mitochondrial Disorders
Pankaj Prasun and Christopher Bare
Icahn School of Medicine, Mount Sinai, NY, USA
042 - LC-MS/MS Measurements of Urinary Guanidinoacetic Acid and Creatine: Method Optimization by Deleting Derivatization Step
Benoit Rucheton, Samuel Amintas, Samir Mesli, Brigitte Colombies, and Isabelle Redonnet-Vernhet
Service de Biochimie, Secteur Maladies Héréditaires Du Métabolisme, Groupe Hospitalier Pellegrin, Ch, Bordeaux, France
Creatine deficiency syndromes include three hereditary diseases affecting the metabolism of creatine (Cr): Guanidinoacetate methyltransferase deficiency, arginine glycine amidinotransferase deficiency, and the deficiency of creatine transporter. These pathologies cause a brain creatine deficiency responsible of non-specific neurological impairments with mental retardation. LC-MS/MS measurements of guanidinoacetic acid (GA) and Cr in urine and plasma are useful for the diagnosis and the identification of one of the deficits. The analysis of these polar and basic molecules is difficult. For the study of these substances, which are not retained on standard column, the reference method requires a derivatization step. To overcome this long and fastidious derivatization, an ion pairing method was chosen. The principle is to add an opposite charging ion to the molecules of interest in the two mobile phases to form an uncharged complex. The opposite charging ion will interact via its hydrophobic chain with the organic stationary phase causing a stronger retention of the complex.
043 - A Targeted Lipid Panel in Plasma for the Diagnosis of Niemann-Pick Types A, B and C Disease, Gaucher Disease, and Cerebrotendinous Xanthomatosis
Coleman Turgeon1, Dietrich Matern1, Piero Rinaldo1, Dimitar Gavrilov1, Devin Oglesbee1, Silvia Tortorelli1, Kimiyo Raymond1, Daniel Ory2, Charles Lourenço3, Roberto Giugliani4, and Lisa Kratz5
1Biochemical Genetics Laboratory, Mayo Clinic College of Medicine, Rochester, MN, USA
2Diabetic Cardiovascular Disease Center, Washington University School of Medicine, St. Louis, MO, USA
3Univerisity Of São Paulo, Ribeirao Preto, SP, Brazil
4Genetics Department, Ufrg, Porto Alegre, RS, Brazil
5Kennedy Krieger Institute, Baltimore, MD, USA
044 - Simultaneous Quantification of Amino acids in Serum by HPLC for the Diagnosis of Aminoacidemias in Cuban Patients
Jiovanna Contreras-Roura, Aurelio David Padrón-Díaz, Alina Concepción Alvarez, Ivette Camayd-Viera, Laritza Martínez-Rey, and Alexis Alles-Gustavo
National Center of Medical Genetics, La Habana, Cuba
Aminoacidemias are metabolic diseases characterized by an excess of amino acids and organic acids in biological fluids. These diseases are caused by an enzymatic deficit in the metabolism of amino acids and present heterogeneous clinical manifestations and variable severity. The early diagnosis of the specific entity is crucial. A reverse phase analytical method was validated by HPLC with precolumn derivatization with sodium phenylisothiocyanate for the simultaneous quantification of 13 amino acids in serum; our aim was to use it in the diagnosis of aminoacidemias. This evaluated specificity, linearity, accuracy, and precision of the method. The validated method was used in the diagnosis of aminoacidemias in pediatric patients with clinical suspicion of the disease. It was also used to perform the biochemical follow-up of the diagnosed patients, in order to assess the efficacy of dietary treatment. The method is specific for amino acids, is linear in the evaluated concentration ranges for each amino acid (r > 0.99 and r 2> 0.98), accurate (% recovered 90-106% and % recovered CV <15%), and precise (% CV <15%). The introduction of the method in the laboratory allowed the diagnosis of maple syrup urine disease (3 patients) and nonketotic hyperglycinemia (3 patients). The HPLC method for the simultaneous quantification of amino acids in serum met the validation criteria for bioanalytical methods and their introduction allowed the diagnosis of aminoacidemias.
045 - Performance Evaluation of Newborn Screening Tests in the SUMA® Automatic Analyzer SUMAutoLab
Amarilys Frómeta, Gustavo Frías, Abel Toledano, Ernesto González, Elisa Castells, Yileidis Tejeda, Evelyn Gato, Lesley Del Río, Pedro Almenares, Alfredo Rego, and Alexander Trujillo
Inmunoassay Center, Havana, Cuba
SUMAutoLab is an automatic analyzer that can be used for neonatal screening purposes. A complete evaluation of this instrument is necessary in order to demonstrate their acceptability. Tests performance parameters should be assessed for evaluating the consistency in the results produced by the instrument.
046 - Development of a Clinical Metabolomics Platform: Biomarker Characterization in Inborn Errors of Metabolism
Sara Violante1, Daniel Cuthbertson2, Carol Ball2, Sander Houten3, and Chunli Yu1
1Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
2Agilent Technologies, Santa Clara, CA, USA
3Department of Genetics and Genomic Sciences, Icahn Institute for Genomics and Multiscale Biology, New York, NY, USA
047 - Validation of UMELISA TSH Neonatal® Using Technical Procedure at Room Temperature (20-25 ºC)
Amarilys Frómeta, Yileidis Tejeda, Ernesto González, Elisa Castells, Odalys Martín, Pedro Lucio Pérez, Maryeris Espinosa, and Yenitse Perea
Inmunoassay Center, Havana, Cuba
UMELISA TSH Neonatal is a quantitative immunoassay for neonatal screening of Congenital Hypothyroidism in dried blood spots. Perfectioning the assay procedure is an important strategy to enhance the performance of the test in laboratories. Functional characteristic assessment allows to demonstrate the reliability of a new analytical procedure.
048 - UMELISA TIR Neonatal: Immunoenzymatic Ultramicroassay for the Determination of Immunoreactive Trypsin (IRT) Levels in Dried Blood Spots on Filter Paper
Elisa Castells, Amarilys Frómeta, Yileidis Tejeda, Ernesto González, Yenitse Perea, Odalys Martín, Maryeris Espinosa, Pedro Lucio Pérez, Lesley Del Río, Greilys Morejón
Inmunoassay Center, Havana, Cuba
049 - Validation of Quantitative Proton Nuclear Magnetic Resonance (q1H-NMR) Spectroscopy for the Clinical Measurement of Urinary Galactitol
Fabienne Parente1, Jeniffer Jayaratnam2, Vesnaver Matthew3, Larroque Anne-Laure4, Sanjoy Kumar Das4, Martine Monette5, Martine Monette5, Sanjoy Kumar Das6, and Larroque Anne-Laure6
1Mcgill University Health Centre, Medical Biochemistry Division, Montreal, Canada
2Mcgill University Health Centre, Montreal, Canada
3Mcgill University Health Centre, Outremont, Canada
4Research Institute of The Mcgill University Health Centre, Drug Discovery Platform, Montreal, Canada
5Bruker Canada Ltd, Milton, Canada
6Research Institute of The Mcgill University Health Centre, Drug Dicovery Platform, Montreal, Canada
050 - Potential Role of Targeted Next-Generation Sequencing in the diagnosis of Niemann-Pick Disease Type A/B: Experience of a Brazilian Reference Center for Lysosomal Diseases
Diana Rojas Malaga1, Ana Carolina Brusius-Facchin2, Kristiane Michelin2, Maira Burin2, and Roberto Giugliani2
1Postgraduate Program in Genetics and Molecular Biology, Ufrgs, Porto Alegre, RS, Brazil
2Medical Genetics Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, RS, Brazil
Niemann-Pick disease types A and B (NPA/B), also known as acid sphingomyelinase deficiency (ASMD), are caused by mutations in SMPD1 gene. Until now more than 220 mutations have been reported in NPA/B patients. The suspicion is usually raised by clinical features and diagnosis obtained by specific biochemical tests including measurement of ASM enzyme activity in dried blood spots, leukocytes, cultured skin fibroblasts, chorionic villus, or amniocytes. Recently, the genetic testing by Sanger sequencing and targeted next-generation sequencing (TNGS) were introduced in our laboratory routine for most lysosomal diseases. We report here the diagnostic work-up in a 15-year-old patient, initially referred for the investigation of Niemann-Pick C disease, who presented unexplained hepatosplenomegaly, with numerous histiocytes in the bone marrow biopsy. Biochemical tests were performed in the patient, including measurement of oxysterols and of the activity of chitotriosidase in plasma, and of lysosomal acid lipase activity in leucocytes, all these results within normal range. The Fillipin test in growing skin fibroblasts was inconclusive. According to our protocol, ASM activity in cultured skin fibroblast was measured, showing an activity of 1.25 nmol/h/mgprot (reference value: 49-72), a result compatible with ASMD diagnosis. This multistep process took approximately 12 months until the diagnosis was reached, in part due to the request of new samples. A previous validated TNGS panel was utilized as second-tier diagnostic approach, including the genes NPC1, NPC2, LIPA, SMPD1, GBA1, PSAP and CHIT1, related to some lysosomal disorders with visceromegaly as common clinical manifestation. We found 2 pathogenic variants in SMPD1 gene: p.Arg610del (c.1826_1828delGCC) and p.Asp420 fs (c.1259delA), the last one being a novel mutation. Both variants were confirmed by Sanger sequencing. Turnaround time for TNGS panel in our laboratory is 2 to 4 weeks. Here, we show that the TNGS panel is a sensitive tool, and may have a faster turnaround time compared to the biochemical approach, demonstrating the potential role for diagnosis of NPA/B in our service. Multigene panel next generation sequencing panels, with confirmation of the functional impact of the findings by biochemical tests, can speed up the definition of the diagnosis, allowing the faster introduction of the appropriate management to the patient and family.
051 - Multiplex Glycosphingolipid Analysis Show Plasma Gb4 and Gb2 Discriminate Female Fabry Patients Better than Lyso-Gb3
Wendy Heywood1, Justyna Spiewak1, Ivan Doykov1, Jenny Hallqvist1, Kevin Mills1, and Albina Nowak2
1University College London, London, United Kingdom
2University Hospital Zurich, Zurich, Switzerland
The glycosphingolipid (GSL) Gb3 is elevated in Fabry disease due to markedly decreased or absent α-Gal A enzyme activity caused by mutations in the α-galactosidase A (GLA) gene. The down- and upstream effects of reduced alpha galactosidase activity on other glycosphingolipids (Gb1, Gb2 and Gb4) in the GSL degradation pathway have not been investigated previously. We have developed a 10-minute multiplex LC-MS/MS GSL assay to quantitate 200+ GSL’s and their isoforms. This can potentially diagnose Fabry, Sandhoff, and Gaucher disease. We have applied this assay to Fabry patient plasma and urine samples to correlate plasma Gb3 and lyso-Gb3 with urine Gb3 and the other GSL’s. Our aim is to investigate the relationship of these 4 glycosphingolipids in Fabry disease in plasma compared to urine and whether they can be informative for the detection of female Fabry patients or response to kidney damage. Plasma GSLs (Gb1-Gb4) were prepared from 50 µL of plasma. Plasma lyso-Gb3 was prepared from 100 µl of plasma. Urine GSLs (Gb1-Gb4) were prepared from 50 µL of urine. Extraction solutions containing internal standards for Gb3 and Gb2 were added. After extraction, samples were reconstituted in methanol prior to analysis on a Xevo TQ-S mass spectrometer and analyzed using multiple-reaction monitoring (MRM). Data were acquired for lyso-Gb3 analogues and Gb1 (glucosylceramide), Gb2, Gb3 and Gb4 (globotetraosylceramide) isoforms to create a profile of Fabry GSLs. Sixty-eight Fabry adult patient samples were analyzed and were grouped according to ERT status, sex, and eGFR stage. Multiple correlation analysis of all isoforms for Gb3 and lyso-Gb3 in plasma and urine showed good correlation with each other in both plasma and urine. However, expression of hydroxylated forms C:16 and C18 Gb3 were independent of Gb3 but demonstrated a correlation with lyso-Gb3 in urine but not plasma. There was a poor relationship between urine and plasma Gb3. Multivariate analysis revealed total plasma Gb4 and C18 Gb2 were better than lyso-Gb3 in detecting female patients however lyso-Gb3 still showed better response to ERT. There was no relationship with decreasing kidney function with any of the GSLs. Concentrations of urinary hydroxylated isoforms of Gb3, Gb2, and Gb1 are independent of the levels of the unmodified GSL. The origin of these hydroxylated species of GSL is unknown but may be due to other biological processes. Plasma is better than urine for detecting females using Gb4 and Gb2.
052 - Congenital Adrenal Hyperplasia: Mutation Detection of CYP21A2 Gene in Cases From Southern Brazil
Mayara Prado1, Cláudia Maria Dornelles da Silva2, Cristiane Kopacek3, Simone Martins de Castro4, Maricilda Palandi de Mello5, Thaiane Rispoli Serrano1, Tarciana Grandi2, and Maria Lucia Rosa Rossetti6
1Cdct/Das/Ses And Ufrgs, Porto Alegre, RS, Brazil
2Cdct/Das/Ses, Porto Alegre, RS, Brazil
3Ufcspa And Hmipv, Porto Alegre, RS, Brazil
4Hmipv And Ufrgs, Porto Alegre, RS, Brazil
5Cbmeg/Unicamp, Campinas, SP, Brazil
6Cdct/Das/Ses And Ulbra, Porto Alegre, RS, Brazil
Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders caused by a defect in one of the enzymes involved in cortisol biosynthesis. In 90% of cases, CAH is due to steroid 21-hydroxylase deficiency. The concentration of 17-hydroxyprogesterone (17OHP), one 21-hydroxylase substrate, is measured in newborn screening programs using biochemical tests. However, the levels of 17OHP can vary by influence of different factors, causing false-positive or false-negative results. Molecular biology assays have been used to clarify and assist such cases.
053 - Automated Nuclear Magnetic Resonance Spectroscopy (NMR) Urinary Analysis: A New Approach for Selective Screening of Inborn Errors of Metabolism (IEM)
Claire Cannet1, Lars Beedgen2, Friedrich Karl Trefz2, Juergen Guenther Okun2, Claus-Dieter Langhans2, Hartman Schäfer1, Manfred Spraul1, Dorothea Haas2, Stefan Koelker2, and Georg F. Hoffmann2
1Bruker Biospin Gmbh, Rheinstetten, Germany
2Center for Metabolic Diseases, Metabolic Laboratory, Heidelberg, Germany
054 - Automated Quality Assessment in Networks of Neonatal Screening Laboratories with SUMA Technology Using the SIGMA, CVI, SDI Estimators
Alfredo Rego, Héctor Leonel Pérez Molina, Niurka Margarita Carlos Pías, Mirta Mayret Rojas Pérez, and Gerardo Baró Román
Inmunoassay Center, Havana, Cuba
Quality Control in the Networks of Neonatal Research Laboratories guarantees the operation of the Health Programs reducing the occurrence of false-positive and false-negative results. The present work shows the results obtained with the development and implementation of Computer Systems developed for the Quality Assessment of laboratories with SUMA Technology based on the calculation of the Sigma, SDI (standard deviation index), and CVI (coefficient variation index). Using current computer tools, the automatic extraction of the results of laboratory controls, sending and automated calculation of evaluative results, reducing the execution time of corrective measures and guaranteeing the confidentiality of the results.
055 - Screening for Fabry Disease: More Than 50,000 Samples of DBS During Seven Years of Experience in São Paulo, Brazil
Marion Braga, Vanessa Gonçalves Pereira, Joyce Umbelino Silva Yamamoto, Rocha Esteves, Beatriz Santos Oliveira, Ana Maria Martins, and Vânia D’Almeida
Universidade Federal de São Paulo, São Paulo, SP, Brazil
Fabry disease (FD, OMIM#301500) is one of the X-linked lysosomal storage disease that could be treated by enzyme replacement therapy, which reinforces the need of accurate diagnostic methods for this disorder. A methodology to screen for FD in large populations, allowing a better outcome with earlier initiation of therapy, has been developed using a fluorometric assay for α-galactosidase A, the enzyme with functional activity deficient in FD, on dried blood spots (DBS) on filter paper.
056 - Renal Function in Fabry Disease: The Importance of the Evaluation of Multiple Parameters
Marion Braga1, Fernando Luiz Affonso Fonseca2, Ana Maria Martins1, and Vânia D’Almeida1
1Universidade Federal de São Paulo, São Paulo, SP, Brazil
2Faculdade de Medicina do Abc, São Paulo, SP, Brazil
Fabry disease (FD) is an X-linked metabolic storage disease due to the deficiency of alpha-galactosidase A (a-GAL) which causes accumulation of glycosphingolipids, causing impairment especially throughout renal, cardiac, and neurological systems. Enzyme replacement therapy (ERT) is recommended when signs, symptoms, or laboratory changes appear. ERT can improve the quality of life for FD patients, including stabilization or improvement in renal function.
057 - Dynamic Next Generation Sequencing Improves Diagnosis for Fetal Hydrops
Tim Pyragius, Kristian Brion, Melissa Gurner, Sharon Chin, Samantha Stark, and Janice Fletcher
National Referral Laboratory, Sa Pathology, Adelaide, Australia
058 - IEMbase: Knowledgebase and Mini-Expert Platform for the Diagnosis of Inherited Metabolic Diseases: Validation, Implementation and Performance
Jessica Jy Lee1, Wyeth W Wasserman2, Georg F. Hoffmann3, Clara Van Karnebeek4, and Nenad Blau3
1Centre For Molecular Medicine and Therapeutics, BC Children’s Hospital Research Institute, Vancouver, Canada
2Genome Science and Technology Graduate Program, University of British Columbia, Vancouver, Canada
3Dietmar-Hopp Metabolic Center, University Children’s Hospital, Heidelberg, Germany
4Departments of Ped And Med Genet, University of British Columbia, Vancouver, Canada
059 - UPLC-HR-MS Assisted Non-Targeted and Targeted NMR Based Screening of Urine
Claire Cannet1, Markus Godejohann1, Lars Beedgen2, Friedrich Karl Trefz2, Juergen Guenther Okun2, Claus-Dieter Langhans2, Hartmut Schäfer1, Manfred Spraul1, Dorothea Haas2, Stefan Koelker2, and Georg F. Hoffmann2
1Bruker Biospin Gmbh, Rheinstetten, Germany
2Center for Metabolic Diseases Heidelberg - Metabolic Laboratory, Germany, Heidelberg, Heidelberg, Germany
060 - A New Approach for Congenital N-Glycosylation Disorders (CDG) Diagnosis Through the Characterization of Intact Transferrin Isoforms by Two-Dimensional LC-MS
Giancarlo La Marca, Bruno Casetta, Sabrina Malvagia, Silvia Funghini, Massimo Mura, Maria Dalla Bona, Giulia Forni, Fabio Villanelli, and Emanuela Scolamiero
University of Florence, Meyer Children’s University Hospital, Firenze, Italy
Different approaches are nowadays devised for applying mass spectrometry (MS) in the characterization of the congenital N-glycosylation disorders (CDG). Most of them target the transferrin (TRF) by looking at its differently glycosylated forms. Some methods exploit the TRF digestion with the subsequent characterization of the generated glycol-peptides. Some others look at the intact TRF forms but after a convenient isolation like planar electrophoresis or immunoaffinity. All the above methods look slightly inadequate for a routine implementation either for labor cost in the sample manipulation or for the use of expensive antibodies. Hereby we present a different approach exploiting a 2-dimensional LC-MS for characterizing the intact TRF forms and by enabling the injection of the serum just diluted. For achieving the scope, a special fluidic system has been devised in order to accomplish the isolation of the TRF forms through an anionic chromatographic separation, followed by a capture on a reverse phase trap, the latter conveniently pre- and post-washed for either avoiding any contamination of the downstream ESI-source by the anionic-chromatographic eluent and for minimizing any carry-over effect. The procedure accomplished in 12 minutes (injection-to-injection) has demonstrated to be very robust in running just-diluted serum samples on a routine scale without any clogging effect. The resulting molecular weight-distribution spectrum clearly shows all the TRF-isoforms, both the normally glycosylated ones and the carbohydrate-deficient forms (CDT). Since this approach has to be correlated to the widely used electrophoretic methodology, hereby presented method is now extensively exploited for building a statistical survey for retrieving the pertinent thresholds. So far, more than 12 positive cases have been confirmed with a calculated % CDT ranging between 15 and 52% for CDG, while the normal values were found up to now between 1.3% and 5.3%. In terms of labor cost for sample preparation and in robustness of the instrumental setting, the protocol has demonstrated to be suitable for a large routine screening.
061 - Drug Repurposing: What If All Marketed Drugs Could be Tested on Every IEM?
Terence Beghyn1, Dries Dobbelaere2, and Camille Moreau1
1Apteeus, Lille, France
2Chru Lille, Lille, France
Apteeus is proposing “STOP Orphan,” a custom and individualized drug discovery program. For the first time, an initiative will give patients the opportunity to start and participate in a research program dedicated to their disease and for the discovery of a treatment. This will reconcile time of research with their lifetime. Apteeus is making possible collaborative projects that imply patients through patients’ association, clinicians, and researchers. The collaborative project consists in (1) developing an in vitro assay based on patient cells obtained from a skin biopsy and which reproduce the patho-physiological mechanisms responsible for the symptoms; (2) testing, on cells from several patients, a unique collection of marketed drugs from all around the world, in the hope that some could unsuspectedly correct the cellular deficiency responsible for the symptoms; and (3) compiling pharmacokinetics and safety properties to assess the opportunity for using an already marketed drug as a clinical candidate in a clinical trial or a compassionate use protocol. This process called “drug repurposing” is clearly less risky and patients’ access to treatment is significantly faster than in case of a new drug. We are initiating the collaborative projects with medical doctors and established researchers in the field. In collaboration, we agree on a scientific plan that is systematically challenged by KOL for any monogenetic affection. In many inherited metabolic diseases, the functional defect caused by the genetic mutation is common to all cells of the body. It then makes possible the development and the use of assays on skin fibroblasts or myoblasts in culture. Moreover, these functional in vitro assays are often already used for diagnosis of IEM diseases. That makes the link between in vitro assays and pathophysiology very strong, and the results directly transposable to the clinic. Apteeus has already settled conditions for mitochondrial, peroxisomal, and lysosomal disorders. The main outcomes of STOP Orphan projects are drug candidates, in vitro assays for testing molecules and for better diagnosis, a better understanding of the biology, the identification of new drug targets, and the biobanking of biological samples that can be used in any new project on the disease. We will describe STOP Orphan process implemented for a 6-year-old boy suffering from a deficiency in ACOX1 peroxisomal enzyme and which is currently treated through a compassionate use protocol.
062 - Diagnostic Capability of Next Generation DNA Sequencing With A 450 Gene Panel for Inborn Errors of Metabolism
Fatih Ezgü, Bahattin Ciftci, Burcu Topçu, Asli İnci, İlyas Okur, Gursel Biberoglu, and Alev Hasanoğlu
Department of Pediatric Metabolic Disorders, Gazi University Faculty of Medicine, Ankara, Turkey
063 - Alternative Method for Lactic Acid Quantification in Biological Samples by Using Isotopic Dilution GCMS
Karen Fuenzalida, Jorge Lobos, Valentina Jorquera, Juan Pablo Rodriguez, and Juan Francisco Cabello
Inta-Uchile, Santiago, Chile
Lactic acid determination in biological samples by gas chromatography-mass spectrometry (GC-MS) has been previously described by Meyer (2011) and Rocchiccioli (2002). Both methods are fast and simple and after derivatization with bis-N, O-trimethylsilyl trifluoroacetamide were analyzed with EI MS in selective ion monitoring mode. The methods differ in the use of internal standard as reference molecule for quantification, while Meyer’s protocol use 1,3 propyleneglycol Rocchiccioli use a synthetized internal standard 3[2 H]-(2 R)-Lactic Acid. We have assessed lactic acid quantification by SIM mode in GCMS using (3,3,3-D3)-L-Lactic Acid as internal standard without consistent results. We observed loss of natural L-Lactic acid in presence of deuterated lactic acid. Some of these inconsistences have been reported. In order to evaluate an alternative labeled Internal Standard for Lactic quantification, we used isotopic orotic acid (1,3-15N2), a reference molecule used in routine form orotic quantification. By using this alternative standard, we found that linear calibration was quantitatively possible and in a reproducible manner as much as for lactic acid present in plasma and urine sample. Also. we could measure lactic acid levels in the conditioned cell culture medium as example for its wide application in clinical and investigation.
064 - Kinetic Study of Plasmatic Alpha-Galactosidase A: Critical Variables for the Diagnosis of Fabry’s Disease
Luiz Carlos Santana-Da-Silva, Felipe Franco, and Camila Aragão
Laboratory of Inborn Errors of Metabolism, Federal University of Pará, Belém, PA, Brazil
065 - Diagnosis and Monitoring of Patients With Glycoprotein Storage Disorders by Novel UPLC-MS/MS Oligosaccharide Analysis
Taraka Donti, Rongrong Huang, Allison Cason, Laura M. Pollard, and Tim Wood
Greenwood Genetic Center, Greenwood, SC, USA
Majority of clinical laboratories utilize thin layer chromatography (TLC) to measure urinary free oligosaccharides (FOS) to identify patients with a variety of inborn errors of metabolism including the glycoprotein storage disorders, Pompe disease, and more recently several congenital disorders of glycosylation. However, TLC is not an optimal assay as it is not quantitative and lacks the sensitivity and specificity of a clinical diagnostic test. We developed a novel, rapid UPLC-MS/MS method to measure urinary FOS using reducing end labeling. The relative concentration of nine disease-specific oligosaccharides is determined by comparison to the peak area of a single internal standard. As an initial validation, we analyzed 51 urine samples from a patient cohort encompassing 8 LSDs: aspartylglucosaminuria (n = 10), fucosidosis (n = 4), alpha-mannosidosis (n = 21), beta-mannosidosis (n = 1), beta-galactosidase deficiency (n = 8), Sandhoff disease (n = 2), sialidosis (n = 3), and galactosialidosis (n = 2), which were collected as part of the Glycoproteinoses Natural History Study or through routine diagnostic testing. Age-specific normal ranges were developed using 110 samples from unaffected controls. An increased abundance of the disease-specific oligosaccharide was identified in all 51 affected individuals. When compared to age-matched controls, the elevations ranged from 5- to 2100-fold, with fucosidosis (1285-fold), sialidosis (426-fold), galactosialidosis (265-fold), and aspartylglucosaminuria (154-fold) showing the widest dynamic range. Urine samples from patients with alpha-mannosidosis, fucosidosis, and beta-mannosidosis post-bone marrow transplantation had significantly lower oligosaccharide levels compared to untreated patients, indicating that this assay can be used to evaluate the efficacy of future treatments. We have also analyzed 80 urine samples from patients with Mucolipidosis types II, II/III, or III and identified at least one FOS abnormality in all ML patients and were also capable of differentiating between MLII and MLIII patients. Identification of significant elevations in urinary FOS specific for Pompe disease (Glc4) and 2 types of congenital disorders of glycosylation suggest the assay can be used as a broad screen for an increasing number of inborn errors of metabolism. Based on the data accumulated so far, our assay is a significant improvement over TLC and is capable of avoiding false positives due to dietary or medication related metabolites.
C) Newborn Screening (066 to 151)
066 - Development of a Novel 24-Plex Newborn Screening Assay
Michael Gelb
University of Washington, Seattle, WA, USA
067 - Genetic Variants of Glucose-6-Phosphate Dehydrogenase (G6PD) in Brazilian Children With Positive Neonatal Screening for G6PD Deficiency, and Correlation With Neonatal Jaundice
Silvana Fonseca1, Camila Nobre2, Dayse Alencar3, Juliana Thomas4, Vinicius Eira5, and Rafael Jácomo2
1Sabin Medicina Diagnóstica, Brasília, DF, Brazil
2Sabin Medicina Diagnóstica, Brasilia, DF, Brazil
3Dle-Diagnósticos Laboratoriais Especializados, Rio de Janeiro, RJ, Brazil
4Secretaria de Estado e Saúde do Distrito Federal, Brasília, DF, Brazil
5Universidade Federal de São Paulo, São Paulo, SP, Brazil
The objective of the current study was to identify the types of variants in the G6PD gene in a group of children screened through the Neonatal Screening Program (NSP) in the Federal District and correlate these data with the presence of neonatal jaundice.
068 - Prediction of Congenital Hypothyroidism Based on Initial Neonatal Screening for Thyroid-Stimulating Hormone at Southwest Colombia (January 2006-March 2017)
Lina Johanna Moreno Giraldo1 and Jose Maria Satizabal Soto2
1Genomics, Cali, Colombia
2Universidad Del Valle, Genomics, Cali, Colombia
Congenital hypothyroidism (CH) is the most common endocrine disease in newborns. It is related to mental impairment and growth retardation. Most infants with CH are normal at birth, emphasizing the importance of screening programs. The optimal screening-TSH cutoff level is critical to ensuring that CH cases are not missed. Some programs choose a standard TSH screen cutoff, often in the 15-30 mIU / L range and consider all newborns below the cutoff as negative for CH.
069 - Informing Parents About a Suspected IMD Diagnosis Following Screening: Key Lessons
Jim Bonham1, Louise Moody2, Lou Atkinson2, and I Kehal2
1Sheffield Children’s Hospital, Sheffield, United Kingdom
2Coventry University, Coventry, United Kingdom
The study objective was to determine the views and experiences of healthcare professionals and parents on communication and interaction during the period of confirmatory testing following a positive screening result. Research indicates that positive screening results can have a negative effect on family relationships, parental depression, and relationships with health-care professionals. The period of confirmatory testing following a positive screening result in particular can cause significant anxiety for the families as they wait for news. The communication and support provided during this time may have a lasting impact on families. Semistructured interviews were undertaken with 10 parents of children who had received a positive ENBS result and 11 health-care professionals who had been involved with the diagnosis and support of parents. Key themes were identified through thematic analysis. The results highlighted the need for careful communication of results to parents, rapid turnaround of results, and a consistent approach. It was clear that parents expect and try to source reliable information online at this time. A need to explore interventions to support family relationships and review the workload and scheduling implications for health-care professionals was highlighted. The development of an app to provide family support and facilitate communication between the family and health-care professionals is now being explored. An initial codevelopment session was run with parents to produce some priorities for the app design. Media content is being developed to explain the confirmatory testing period to parents for 3 conditions (MSUD, HCU, and GA1). In the long term, as well as information, it is expected that a self-management resource may be useful to parents and allow services to provide an ongoing support system. As technology enables newborn screening for a larger number of conditions, there is an increasing need to consider and mediate the potential negative effects. The findings from this study point to a number of elements within the path through confirmatory testing that are difficult for parents and may be suitable for support online and through a smartphone app.
070 - To Screen or Not to Screen? Experiences With Candidate Newborn Screen Conditions Across 3 States
Sarah Viall1, Jennifer Macdonald2, Johnna Watson3, and Nicholas Ah Mew1
1Rare Disease Institute, Seattle, WA, USA
2Virginia Department of Health, Richmond, VA, USA
3Maryland Department of Health and Mental Hygiene, Baltimore, MD, USA
Newborn screening (NBS) is a state-based public health program identifying babies with critical, treatable inherited conditions at birth across the United States. Rapid advances in screening, diagnostics, and therapeutics have dramatically expanded the number of candidate conditions for blood spot screening. While recommendations are made by a federally supported entity, the Advisory Committee on Heritable Disorders in Newborns and Children, ultimately every state is responsible for determining, financing and supplementing additions to their programs. This has led to great variability in process and timeline for new disorders, particularly the lysosomal storage diseases, which some states have added and others have decided to exclude. Our Newborn Screening Follow-Up Program serves as a referral center for three jurisdictions, each with different disease pipelines. This has presented some unique challenges and valuable learning opportunities. Herein we summarize our active involvement in this process in the District of Columbia, Maryland, and Virginia.
071 - Hemoglobin Kawachi: First Case Found in Uruguay
Paola Audicio1, Betsey Segobia1, Tarciana Grandi2, Simone Martins de Castro3, and Cecilia Queijo1
1Laboratorio de Pesquisa Neonatal -Bps, Montevideo, Uruguay
2Laboratório de Genética Molecular Humana, Centro de Desenvolvimento Científico e Tecnológico, Porto Alegre, RS, Brazil
3Serviço de Referência Em Triagem Neonatal e Ufrgs, Porto Alegre, RS, Brazil
072 - Investigating Applications of Next Generation Sequencing for Newborn Screening
Jim Bonham1, Clare Gladding1, Antonio Milano1, Julia Van Campen1, Jennifer Dawe1, Gerrard Peck1, Peter Winship1, Sian Richards1, Mark Sharrard1, Diana Johnson1, Lyndsay Weaver2, Anne Goodeve1, Ann Dalton1, and Darren Grafham1
1Sheffield Children’s Hospital, Sheffield, United Kingdom
2Climb, Crewe, United Kingdom
In newborn screening (NBS) programs, dried blood spot (DBS) samples are used to identify babies with rare, often fatal, but treatable disorders. Biochemical analysis is performed at low cost with short turnaround times. However, it can be challenging to predict disease severity and appropriate treatment in asymptomatic individuals or for disorders lacking a suitable biochemical analyte or enzyme assay. This project is investigating the use of next generation sequencing (NGS) to: (1) improve the diagnostic and prognostic utility of existing UK NBS programs and (2) assess the technical feasibility of using NGS as a primary or adjunct screening test.
073 - Newborn Screening for Arginase Deficiency in the U.S.: Where Do We Need to Go?
Stephen Cederbaum1, Brad Therrell2, David Lapidus3, Robert Currier4, and Meredith Grimm5
1University of California–Los Angeles, Los Angeles, CA, USA
2University of Texas, San Antonio, Austin, TX, USA
3Lapidus Data, Tulsa, OK, USA
4California Department of Public Health, Richmond, VA, USA
5Aeglea Biotherapeutics, Austin, TX, USA
Arginase 1 catalyzes the final step of the urea cycle, hydrolyzing arginine to ornithine and urea. When arginase 1 is mutated, arginine accumulates (hyperargininemia). Arginase 1 deficiency (ARG1-D) is rare with an estimated frequency of 0.5/106 to 1.1/106 live births. A newborn screening test with a low specificity would cause an unacceptably high false-positive rate. Failure of early detection and delays in clinical management frequently results in irreversible cognitive and neurological complications which may be treatable. Currently, ARG1-D is recommended as a secondary target for newborn screening in the U.S. Elevation in status to a “core” condition on the Recommended Uniform Screening Panel (RUSP) would result in more babies being screened, diagnosed, and treated. We surveyed all state newborn screening programs and the District of Columbia in order to ascertain current ARG1-D screening activities of the 51 U.S. programs. We confirmed that the screening laboratory methodologies and algorithms vary widely. Most screening programs rely on arginine concentrations to determine patient risk for hyperargininemia, but action levels vary. Some programs include ratios of arginine to other amino acids but a consistent approach to their use does not appear to exist. While many programs include hyperargininemia as a screening requirement, some do not, and in others the laboratory screening protocol may detect hyperargininemia even though it is not formally a part of the screening panel. Although hyperargininemia screening exists in 76% of U.S. jurisdictions, an overall lack of harmonization in screening methodologies suggests that national data sharing to evaluate arginine cutoffs, and the value of various ratios in establishing a model screening algorithm are needed. We report here as well data from the California Newborn Screening program which demonstrate that all 9 cases of Arginase 1 Deficiency in the past 6 years would have been detected using a low cutoff value of 50 µmol/L, and the ratios of arginine to ornithine and arginine to phenylalanine × isoleucine as suggested by the R4 S program developed at the Mayo Clinic. The sensitivity and specificity were each approximately 100%, meaning that there were no false positives in 5.4 million births. Arginase 1 deficiency can be screened with very high efficiency and is a candidate to be added to the RUSP.
074 - Late Diagnosed Phenylketonuria
Ana Bernal and Hernan Eiroa
Hospital Garrahan, Buenos Aires, Argentina
075 - Enzyme Activities of Lysosomal Storage Disorders in a Neonatal Population of Japan
Ryuichi Mashima and Torayuki Okuyama
National Center for Child Health and Development, Tokyo, Japan
Lysosomal storage disorders (LSDs) are caused by the defective enzyme activities in the lysosomes characterized by the accumulation of oligosaccharides, glycolipids, sphingolipids, and mucopolysaccharides. Growing evidences have suggested that the earlier detection of the affected individuals followed by an immediate initiation of appropriate therapy during the presymptomatic period usually results the better therapeutic outcomes. For this reason, simultaneous determination of multiple enzyme activities seems to be more favorable to neonatal screening for LSDs because of the low prevalence of an individual LSD. Thus, in this study, we examined the assay procedure of 6 LSD enzyme activities by LC-MS/MS-based method. Within our assay conditions, the accumulation of enzyme products was almost linear for 0 to 20 hours at 37°C and over 0% to 100% enzyme activity when CDC-provided dried blood spots were used for quality control. The values of coefficient of variance within a day and between days were less than 25%. Importantly, the enzyme activities of healthy individuals were higher than those of disease-confirmed individuals. These results suggest that the levels of enzyme activities of these LSDs of a neonatal population in Japan were comparable to the recent report [Elliott S et al Mol Genet Metab 118 (2016): 304-309], further extending an evidence that 6-plex LSD enzyme assay provides a promising analytical procedure for neonatal screening.
076 - Glycosaminoglycan Assay as First-Tier for MPS Newborn Screening
Francyne Kubaski1, Robert W. Mason2, Akiko Nakatomi3, Haruo Shintaku4, Li Xie2, Naomi Van Vlies5, Heather Church6, Roberto Giugliani7, Hironori Kobayashi8, Seiji Yamaguchi9, Yasuyuki Suzuki10, Tadao Orii11, Toshiyuki Fukao11, Adriana M. Montaño12, and Shunji Tomatsu2
1Hcpa/Inagemp, Porto Alegre, RS, Brazil
2Nemours/Alfred I. Dupont Hospital for Children, Wilmington, DE, USA
3Department of Pediatrics, Nagasaki University, Nagasaki, Japan
4Department of Pediatrics, Osaka City University Graduate School of Medicine, Osaka, Japan
5Laboratory Genetic Metabolic Diseases Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
6Willink Biochemical Genetics Unit Regional Genetics Laboratory Genetic Medicine, St Mary’s Hospital, Manchester, United Kingdom
7Ufrgs/Sgm-Hcpa/ Inagemp, Porto Alegre, RS, Brazil
8Department of Pediatrics, Shimane University, Izumo, Japan
9Department of Pediatrics, Shimane University, Izumo, Japan
10Medical Education Development Center, Gifu University, Gifu, Japan
11Department of Pediatrics, Gifu University, Gifu, Japan
12Saint Louis University, St Louis, MO, USA
Mucopolysaccharidoses (MPS) are lysosomal storage disorders characterized by progressive accumulation of glycosaminoglycans (GAGs) due to deficiency of specific lysosomal enzymes. All types of MPS are chronic and progressive with extensive range of clinical manifestations highlighting a need for early diagnosis, especially as many of these conditions are now treatable. This pilot study analyzed 17 467 dried blood spots (DBS) from general newborns and 14 DBS from newborn patients with MPS (7MPS I, 2 MPS II, and 5 MPS III). Disaccharides were produced from polymer GAGs by digestion with chondroitinase B, heparitinase, and keratanase II. Heparan sulfate (0 S, NS), dermatan sulfate (DS), and mono- and di-sulfated KS were measured by liquid chromatography tandem mass spectrometry (LC-MS/MS). Median absolute deviation (MAD) was used to determine cutoffs to distinguish patients from controls. Cutoffs were defined as median + 7x MAD from general newborns. The cutoffs were as follows: HS-0S> 90 ng/mL; HS-NS> 23 ng/mL, DS> 88 ng/mL; monosulfated KS> 445 ng/mL; disulfated KS> 89 ng/mL and ratio di-KS in total KS> 32%. All MPS I and II samples were above the cutoffs for HS-0 S, HS-NS and DS, and all MPS III samples were above cutoffs for HS-0 S and HS-NS. The rate of false positives for MPS I and II was 0.07% based on a combination of HS-0 S, HS-NS, and DS and for MPS III was 1.3% based upon a combination of HS-0 S and HS-NS. Combination of levels of two or more different GAGs improves separation of MPS patients from unaffected controls, indicating that GAG measurement is a potentially valuable tool for first-tier newborn screening of MPSs, especially by the fact that a single test can screen for several distinct MPS. Positive samples for the first tier will be followed by enzyme assay (second tier). Early detection will also affect the choice of the most adequate treatment as well as reduce mortality, morbidity, and public health costs. This GAG-assay also enables treatment efficacy measurements.
077 - Prevalence of Hemoglobinopathies in a Heterogeneous Population of Bogotá, Colombia: A Pilot study
Gustavo Giraldo1, Fernando Suarez-Obando2, and Juan Prieto2
1Clínica Universitaria Bolivariana, Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia
2Pontificia Universidad Javeriana, Facultad de Medicina. Instituto de Genética Humana, Bogotá, Colombia
078 - Decreased Citrulline on Newborn Screening in a Carrier for Carbamoylphosphate Synthetase I Deficiency
Jessica Albert1, Lisa Kratz1, Carolyn Applegate2, Krista Sondergaard2, Celide Koerner2, and Meral Gunay-Aygun2
1Kennedy Krieger Institute, Baltimore, MD, USA
2Johns Hopkins University School 0f Medicine, Baltimore, MD, USA
Decreased citrulline is reported by some newborn screening (NS) laboratories as a marker for proximal urea cycle defects: N-acetylglutamate synthetase (NAGS), carbamoylphosphate synthetase (CPS), and ornithine transcarbamoylase (OTC) deficiencies. The plasma amino acid pattern of low citrulline, increased glutamine–citrulline ratio, and low arginine in association with increased urinary orotic acid is diagnostic for OTC deficiency, whereas the same pattern in the absence of orotic aciduria suggests CPS1or NAGS deficiency. Citrulline may also be low in some mitochondrial disorders and in patients with intestinal disorders such as short gut syndrome. We present an asymptomatic term female identified to have low citrulline (3 µmol/L; N>5) on her second NS performed at age 9 days, confirmed by follow-up testing in plasma at age 21 days (Citrulline: 7 µmol/L, Arginine: 54 µmol/L, Glutamine: 644 µmol/L, Alanine: 301 µmol/L). Plasma ammonia and urine orotic acid levels were normal. Subsequent amino acid analyses revealed persistently low citrulline, despite citrulline supplementation at 30 mg/kg/day and 90 mg/kg/day, initiated at 5 and 7 months of age, respectively. Citrulline remained low until the dose was increased to 143mg/kg/day at age 8 months. Sequencing and deletion/duplication analysis of the OTC, NAGS, and CPS1 genes revealed a novel, likely pathogenic variant, c.1165-2A>G, in CPS1. While it is possible that the patient has a mild pathogenic mutation that escaped detection in trans with this allele, she is most likely a carrier for CPS1 deficiency. We refrained from mitochondrial testing as her brother succumbed to a mitochondrial disorder which was ruled out in this patient by prenatal testing. In conclusion, we add carrier status for CPS1 deficiency to the list of causes for low citrulline identified by NS. Currently, there is no consensus on the usefulness of low citrulline as a marker for proximal urea cycle defects because its positive predictive value is low. Whether to perform further evaluation for mitochondrial disorders in these individuals also remains controversial, as the age of onset of symptoms is variable and no preventive treatment exists. Thus, careful consideration should be given to the approach for follow-up evaluation of a low citrulline level identified by NS in asymptomatic infants, as the cost and unnecessary anxiety caused by additional testing may out-weigh the potential benefits of such testing.
079 - Results of the Neonatal Screening Program in Cuba: 31 Years of Experience
Aramís Sánchez, Eladio Silva, Ana L. Arteaga Yera, Jacqueline Martínez Romero, and Héctor Leonel Pérez Molina
Inmunoensayo Center, La Havana, Cuba
080 - Interlaboratory Comparison of Bloodspot Total Homocysteine Results for Expanded Newborn Screening Second-Tier Testing in England and Wales
Adam Gerrard1, Stuart Moat2, Rachel Carling3, and Mary Anne Preece1
1Birmingham Women’s And Children’s Nhsft, Birmingham, United Kingdom
2University Hospital of Wales, Cardiff, United Kingdom
3Guy’s And St Thomas’ Nhsft, London, United Kingdom
The objective of the study was to ensure comparability of results between the 3 laboratories providing bloodspot total homocysteine analysis for newborn screening second-tier testing in England and Wales. Expanded newborn bloodspot screening to include homocystinuria (HCU; cobalamin non-responsive cystathionine beta-synthase deficiency) commenced in January 2015 in England and Wales. Bloodspots found to have a methionine ≥50 µmol/L are referred for second-tier total homocysteine analysis. Patients are identified as “screen positive” if the bloodspot total homocysteine is ≥15 µmol/L. The bloodspot total homocysteine methods are calibrated using aqueous L-homocysteine calibrators. Second-tier testing is currently provided by 3 centers: Viapath at St Thomas’ Hospital (London), Birmingham Children’s Hospital (Birmingham), and University Hospital of Wales (Cardiff). When expanded newborn bloodspot screening was introduced, no external quality assessment (EQA) scheme was available for total homocysteine. Over a 2-year period, 48 bloodspots were distributed between the three testing laboratories. Bloodspots were made from whole blood hemolysate spiked with L-homocysteine at six concentrations (to give 0, 5, 10, 20, 40, and 80 µmol/L homocysteine). Bloodspots were stored at −20°C and were stable over this time. The six bloodspot levels were distributed in a semi-randomized pattern, with each level distributed eight times over the period. The results were collated and analyzed to show between-laboratory performance. The coefficient of variation between laboratories was lowest close to the screening cutoff (12% at 16.5 µmol/L) and highest at low concentrations (37% at 4.2 µmol/L, base material). The mean recovery of total homocysteine from the bloodspots was approximately 30% for spiked concentrations between 10 and 80 µmol/L but was lower at 21% for the 5 µmol/L spike. To conclude, while the between-laboratory variation close to the screening cutoff has been shown to be acceptable in England and Wales, the recovery of total homocysteine from spiked bloodspots is low. The current lack of independent EQA provision for second-tier newborn screening tests is not ideal; the proposed pilot EQA scheme to be provided by ERNDIM is therefore welcomed.
081 - External Quality Assessment of Neonatal Screening in Cuba: A Three decades Overview
Héctor Leonel Pérez Molina, Ariel Palenzuela Díaz, Niurka Margarita Carlos Pías, Alfredo Rego, Grisell de La Asunción Turró Grau, Gerardo Bara Román, and Mirta Mayret Rojas Pérez
Centro de Inmunoensayo, Havana, Cuba
For over three decades we have been applying an External Quality Assurance Program (EQAP) as an important analytical support to more than 150 laboratories that currently perform Neonatal Screening in Cuba, using SUMA® technology to more than 98% of newborns. The aim of this report is to present the results of the implementation of this EQAP scheme and its influence on quality performance of neonatal screening programs in our country. Control samples with different concentrations values of every analyte (TSH, T4, 17-OH Progesterone, GAL, and Phe) were delivered every 6 months to the participant. The results of variables as Average Index of Variance (AIV) and Average Index of Accuracy (AIA), with a monthly, semestral an annual periodicity were statically evaluated with specifically designed software. At their introduction, relatively high values were observed for both indexes with every test; later on, with gained experience and analytical technical assistant when needed, the indexes were progressively improved, reflecting a better precision within and between laboratories (coefficient of variations lower than 10% and 15%, respectively). Our results sustain the importance of the implementation of a quality control scheme as a component of a screening program supported on a laboratory network, providing a mean of supervision of the analytical performance and managing for quality improvement.
082 - Next Generation Sequencing and the Slovenian Newborn Screening Program
Andraz Smon1, Barbka Repic Lampret1, Urh Groselj1, Mojca Zerjav Tansek2, Jernej Kovac1, Dasa Perko1, Sara Bertok1, Katarina Trebusak Podkrajsek2, and Tadej Battelino2
1University Medical Centre Ljubljana, Ljubljana, Slovenia
2University Medical Centre Ljubljana & University of Ljubljana, Ljubljana, Slovenia
Many countries in Europe have an expanded newborn screening (NBS) program using tandem mass spectrometry, while it is still not implemented in any south-eastern European country. Since the expansion of current screening programs is one the major goals of health-care programs in south-eastern Europe, we conducted a pilot study of expanded NBS in Slovenia with 10 048 included participants. 85 of them were chosen based on abnormal metabolites measured in newborn dried blood spots (DBS) and were analyzed at a metabolic follow-up consisting of the following analyses: acylcarnitines and amino acids in dried blood spots, amino acids in plasma and organic acids in urine. 75 participants, out of 85 analyzed at metabolic follow-up, were analyzed with next generation sequencing (NGS) for selected inborn errors of metabolism (IEM) using a specifically designed gene panel. Altogether, glutaric academia type 1 was confirmed in one patient who was a compound heterozygote for two known causative GCDH variants. A patient with very long-chain acyl-CoA dehydrogenase had two heterozygous ACADVL variants; one known disease causing variant and one indel, namely, c.205-7_-8delCTinsGC predicted to be causative. Nine participants were found with elevated metabolites characteristic for 3-methylcrotonyl-CoA carboxylase deficiency. 2 of them had known causative homozygous variant in MCCC1, while the other 7 participants were heterozygous and 2 of them had a novel genetic variant c.149_151dupCCA (p. Thr50dup). Two participants, one with classical PKU and one with hyperphenylalaninemia, were already confirmed within the existing screening program. Our study demonstrates that cumulative incidences of IEM in Slovenia are similar to the incidences in developed European countries, which have an expanded NBS program running for years. NGS is nowadays being implemented into NBS, either as a first-tier screening test or as a follow-up test of abnormal screening results. NGS as a confirmatory testing proved to be a valuable tool in our study as it explained the abnormal metabolites in DBS, enabled the differentiation between truly affected patients and mere heterozygotes and improved the turnaround time of genetic analyses.
083 - Average Value of 17-OH Progesterone in Different Weights in the INSTITUTO MEXICANO DEL SEGURO SOCIAL Guanajuatós (IMSS) Population
Nohemi Cervantes1, Jhoab Arturo Barajas Escalera1, Edgar A. Cruz1, Natalia Luque2
1Instituto Mexicano Del Seguro Social, Leon Guanajuato, Mexico
2Universidad de La Salle, Leon Guanajuato, Mexico
084 - Development and Evaluation of a Protocol for Diagnosis Confirmation of Cases With Abnormal Newborn Screening Results for Mucopolysaccharidosis I
Heydy V. Bravo Villalta1 and Roberto Giugliani2
1Post-Graduate Program of Genetics and Molecular Biology (Ppgbm), Ufrgs, Porto Alegre, RS, Brazil
2Medical Genetics Service, Department of Genetics, Hcpa, Ufrgs, Porto Alegre, RS, Brazil
085 - Improvement in the Sensitivity of Newborn Screening for Fabry Disease Among Females Through the Use of a High-Throughput and Cost-Effective Method, DNA Mass Spectrometry
Dau-Ming Niu1, Yung-Hsiu Lu2, Po-Hsun Huang2, Li-Yun Wang3, Ting-Rong Hsu1, Hsing-Yuan Li1, Pi-Chang Lee1, Yu-Ping Hsieh1, Sheng-Che Hung4, Yu-Chen Wang5, Chang Sheng-Kai1, Ya-Ting Lee1, Ping-Hsun Ho1, and Hui-Chen Ho3
1Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan, Taipei, Taiwan
2Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan, Taipei, Taiwan
3Taipei Institute of Pathology, Taipei, Taiwan, Taipei, Taiwan
4Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, Taipei, Taiwan
5Department of Pathology and Laboratory Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, Taipei, Taiwan
086 - Incidence of Six Lysosomal Storage Diseases in a Mexican Newborn Screening Program
Consuelo Cantú-Reyna, Héctor Cruz-Camino, Alexandra V. Zea-Rey, René Gómez-Gutiérrez
Genomi-K Sapi de Cv, Monterrey, Mexico
Lysosomal storage diseases (LSD) are a group of more than 50 genetic disorders in which there is a decrease or an absence of activity, inadequate lysosomal enzyme, or carrier proteins biogenesis producing progressive accumulation of precursor metabolites within the lysosomes that result in cellular dysfunction and multiple organ system failure. Currently, there are no comprehensive studies that show the incidence or prevalence in Mexico for LSD. We retrospectively analyzed 44 784 newborn screening (NBS) reports storage in our database between January 26, 2012, and April 27, 2017. Each sample was placed on filter paper and processed by tandem-mass spectrometry at PerkinElmer Genetics (Bridgeville, PA). Six different LSD were studied, including Pompe disease, Fabry disease, Gaucher disease, mucopolysaccharidosis type I (MPS-I), Niemann-Pick type A/B disease, and Krabbe disease. The protocol followed to get an LSD diagnosis began with an NBS first sample showing a decreased enzymatic activity, a second sample with an abnormal result, performing as confirmatory testing serum enzymatic activity and/or gene sequencing. For the 44 784 NBS reports analyzed, 21 882 were female and 22 902 were male. On average, the NBS was performed at 5.27 days of age ±5 days. After the second sample, we found 45 LSD abnormal results. The diagnosis was confirmed in 24 newborns (1 for Niemann-Pick, 15 for Pompe, 7 for Fabry, and 1 for MPS-I). Furthermore, 6 newborns were identified as heterozygous (2 for Niemann-Pick, 3 for Pompe, and 1 for Krabbe). The last 15 newborns were ruled out after a normal confirmatory test. The false-positive rate for the NBS was 0.047%. On the other hand, the positive predictive value was 53.33%. Noteworthy that the newborns confirmed with an LSD were diagnosed approximately at 54 days ±27 days after the collection of the first sample. The incidence of the 6 LSD studied in a Mexican newborn population was 5.36 cases per 10 000 newborns, being Pompe disease the most frequent (3.35:10 000). Carrying out an expanded newborn screening that includes these LSD has allowed us to establish an early diagnosis, initiate an appropriate and timely treatment in order to improve their quality of life. Moreover, genetic counseling was given. In our experience, a prompt diagnosis is achieved thanks to a close follow up by the integration of all parties participating in the NBS program (laboratory, medical staff, parents, and social workers, among others).
087 - Efficient and Effective Newborn Screening for Early Infantile Krabbe Disease
Dietrich Matern1, Silvia Tortorelli1, Dimitar Gavrilov1, Devin Oglesbee1, Kimiyo Raymond1, Jeremy Hart2, Lea Mott2, Joanne Kurtzberg3, Vinod Prasad3, and Piero Rinaldo1
1Mayo Clinic, Rochester, MN, USA
2Kentucky Department for Public Health, Frankfort, KY, USA
3Duke University Medical Center, Durham, NC, USA
Newborn screening (NBS) for Krabbe disease (KD) has been conducted primarily by measuring galactocerebrosidase (GALC) activity and employing molecular genetic analysis of the GALC gene as a second-tier test. Based on NBS data from New York the incidence of KD is unexpectedly low (1:500 000 in NY), while many individuals (ca. 1:5600) with reduced GALC activity and genotypes of uncertain significance are detected and subjected to follow up testing. We and others have shown previously that Psychosine (PSY) is a marker of active KD and can be measured in dried blood spots (DBS). Therefore, we applied it as a second-tier test to NBS for KD along with post-analytical interpretive tools created using Collaborative Laboratory Integrated Reports (CLIR; https://clir.mayo.edu) and molecular genetic analysis of GALC. Among more than 60 000 newborns screened, we identified one case with reduced GALC activity (0.18 nmol/mL/h; first percentile of controls: 1.36), a high CLIR score for Krabbe disease (788; informative >30), significantly elevated PSY (61 nM; controls <10), and a genotype including a heterozygous pathogenic deletion, a heterozygous likely pathogenic frameshift mutation as well as a heterozygous and a homozygous pseudodeficiency allele. The NBS specimen was received in the laboratory on the fourth day of life (a Saturday), the report was released on the sixth day of life, the patient was admitted to the Pediatric Blood and Marrow Transplant Program at Duke University Medical Center on the seventh day of life, received a hematopoietic stem cell transplant (HSCT) on the 23rd day of life and was discharged to home on the 104th day of life. At now 5 months old the patient is developing appropriately for age with minor transplant related concerns. Based on our experience to date, we postulate that NBS for early infantile KD is possible without false positive results and without the need for molecular genetic testing in the NBS laboratory. The biochemical genetic screening approach enables rapid identification of early infantile KD which is of utmost importance to ensure best possible outcomes of HSCT. As our case illustrates, 7-day operation of the NBS laboratory is also required to achieve best outcomes. Whether a biochemical-genetics-only approach is sufficient to detect all cases with later onset variants of KD remains to be determined. Meanwhile relevant stakeholders must continue an open and honest discussion about the achievable goals of NBS for KD.
088 - Newborn Screening for Inborn Errors of Metabolism by Tandem Mass Spectrometry in Cali, Colombia
Myriam Arevalo1, Nora Cespedes2, Angela Valencia2, Carlos Echeverry2, Yolanda Cifuentes3, Paula Margarita Hurtado4, Jose Angel Cocho5, Cristóbal Colón5, Daisy E. Castiñeiras5, and Maria Cristina Lesmes6
1 Faculty of Health, Malaria Vaccine and Drug Development Center, Asoclinic Inmunología, U. Del Valle, Cali, Colombia
2Malaria Vaccine and Drug Development Center (MVDC), Cali, Colombia
3Facultad de Medicina, Universidad Nacional, Bogotá, Colombia
4Faculty of Health Sciences, Pontificia Universidad Javeriana, Cali, Colombia
5Laboratorio de Metabolopatías, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain
6Secretaria de Salud Del Valle, Cali, Colombia
Inborn errors of metabolism (IEM) are genetic disorders causing serious, degenerative, chronic diseases affecting different organs and metabolic systems leading to mental retardation, physical disability and death. Laboratory diagnose of these diseases has evolved through the last two decades from identification of individual disorders using thin layer chromatography, enzymatic methods and high-performance liquid chromatography, to the recent use of tandem mass spectrometry (MS/MS) which allows simultaneous evaluation of multiple metabolites associated with IEM with high sensitivity, low false-positive rates, and high throughput. MS/MS was recently implemented in Cali (Colombia) to determine amino acids, acylcarnitines, succinylacetone, and galactose IP levels in dried blood spots (DBS) of newborns. In a pilot cross-sectional study conducted recently, blood samples of 891 healthy neonates from Cali (n = 523) and Quibdó (n = 368) were analyzed for 57 analytes which allow the diagnosis of >40 different IEM. Blood samples (∼50 mL) from healthy neonates 2-18 days of age (52% male and 48% female) were processed by stable isotope dilution method using Isotopically labeled internal standards from Cambridge Isotope Laboratories, Inc., and analyzed in a 3200 QTRAP MS/MS equipment (AB Sciex). The method showed to be linear, precise and accurate; age-related differences on the concentration levels of amino acids and acylcarnitines were observed, whereas no significant differences by gender were found. Simultaneously, newborns with clinical risk of IEM were tested and two Propionic acidemias, one Methylmalonic acidemia and one Glutaric acidemia Type II, were identified, the last with a fatal outcome. A second DBS and a urine samples were taken from those patients for a second analysis in Cali as well as at the Santiago de Compostela’s Clinic Hospital in Spain and results were confirmed. This is the first report about the implementation of a method by MS/MS to analyze characteristic metabolites for IEM diagnosis in Colombia. Detection of these 4 positive IEM cases suggest that the prevalence of these diseases might be most frequent that expected. As follow up we are currently initiating a study to determine the prevalence of metabolism-dependent diseases determined by MS/MS in a sample of 30 000 healthy corresponding to ∼58% of the total of newborns/year and 1500 risk cases in four municipalities of Valle department in alliance with the State Health Secretary.
089 - Galactosemia as Cause of Neonatal Sepse in Newborn Without Previous Risk Factors for Infections
Roberta Serra, Fatima Cristina Jose, Valeria Fraga, Clarice Francisco
Hospital Maternidade Herculano Pinheiro, Rio de Janeiro, RJ, Brazil
Galactosemia is a metabolic disorder diagnosed in the neonatal period through simple screening tests (“test of the foot”), incidence is 1:18000 (classical form) ranging up to 1: 50000 (depending on the source searched), with no predilection for sex. It is a genetic disease of the autosomal recessive type, which is part of the group of inborn errors of metabolism. It is characterized by the inability to convert galactose to glucose and consequently the accumulation of galactose-1-phosphate in nerve, liver, kidney, and crystalline tissue cells. Galactosemia can be classified into three subtypes. Newborns with galactosemia are more prone to septicemia, with significant frequency of neonatal deaths caused by septicemia by gram negative germs, mostly multiresistant and mainly E. coli. The aim of this work is to illustrate, through a case report, the possibility of galactosemia as a facilitator of late neonatal sepsis in a newborn vaginal birth, term, without complications, who was discharged within 48 hours and returned later with clinical and laboratory findings of severe neonatal sepsis. The newborn does not have any risk factors for neonatal sepsis and prenatal exams within normal limits. Cycles of wide-spectrum antibiotic therapy, mechanical ventilation, and vasoactive amines were required. The associated cholestasis, the patient’s poor response to treatment, crop results, difficult to control hypoglycemia, and the severity of the case were factors that called attention to the possibility of the presence of the associated diagnosis of inborn metabolism error. Suspecting is the key. It was an observational work whose methodology was the retrospective analysis of the medical chart of this newborn and bibliographic review on the subject. In addition, the inclusion of galactosemia screening in the National Neonatal Screening Program (“foot test”) could increase the chance of early diagnosis by improving quality of life both by introducing dietary measures and by increasing cases eligible for outpatient follow-up. It would also increase the chance of prevention of possible complications, including those related to severe neonatal sepsis and the incidence of neonatal deaths. Neonatal sepsis is an important cause of death in this age group. It leads not only to emotional sequelae in families as possible socioeconomic sequelae. Any effort to improve the causal diagnosis and to be able to help in prevention and treatment is of extreme value for neonatology.
090 - G6PD Deficiency in Newborns at the Rafael Calvo Maternity Clinic in Cartagena de Indias: Pilot Study
Ciro Alvear1, Carlos Moneriz1, Cristian Castro1, Darío Méndez1, Erika Rodríguez1, Amalia Diez2, and Jose Bautista2
1Universidad de Cartagena, Cartagena, Colombia
2Universidad Complutense, Madrid, Spain
091 - “Are We Doin’ it Good, Boss?”: Maintaining Quality Newborn Screening
Zena Junek and Veronica Wiley
NSW Newborn Screening Programme, Sydney, Australia
The NSW Newborn Screening Program aims to maintain and improve a high-quality screening program. There are many things to consider when assessing what is “quality newborn screening.” A newborn screening program encompasses pretesting; sample testing and patient follow-up. Quality improvement involves looking at all aspects of our program. The NSW Newborn Screening Program is under constant review to improve the quality of what we do. We observe aspects that are both internal and external to the laboratory. As a program, we deal with what happens before the sample is collected, collection of the sample, testing of the sample, delivering results, and follow-up till diagnosis or exclusion of a disorder. Each aspect is reviewed separately using methods that are diverse and suitable for that aspect. This can be through database information, questionnaires, community awareness, observation. Each aspect of the process is reviewed by relevant members of our team to look for ways to improve the quality of our program. ISO15189 accreditation processes assess quality of the scientific portion of the program. The NSW Newborn Screening Program is accredited with National Association of Testing Authorities, Australia, and quality certified. Currently, we use Human Genetics Society of Australasia key performance indicators to assess some other aspects of screening quality. Percentage of specimens in transit for 4 days or less increased from 78% in 2007 to a peak of 87% in 2014 and in 2016 was 85%; where the target is 95%. Percentage of unsuitable samples has decreased from 0.88% in 2007 to 0.54% in 2016, where the target is <0.5%. The median day of specimen collection was day 3 in 2007 and day 2 in 2016, where the target is 95% collected between 48 and 72 hours of age. Quality is not static and needs to be evaluated frequently. It is important to schedule review and, if appropriate, update all aspects of newborn screening, not just scientific methods.
092 - Metagene (www.metagene.de): Knowledgebase for Diagnostic Support of Inborn Errors of Metabolism (IEM)
Georg Frauendienst-Egger1, Friedrich Trefz2, Hermann Goetz3, Nastassja Himmelreich2, Dorothea Haas2, and Claus-Dieter Langhans2
1Kreiskliniken Reutlingen, Reutlingen, Germany, Reutlingen, Germany
2Dietmar-Hopp-Stoffwechselzentrum Zentrfür Kinder- Und Jugendmedizin, Universitätsklinikum Heidelberg, Heidelberg, Germany
3Tdb Software Company, Schwabach, Germany
093 - Congenital Hypothyroidism in Nicaragua: Etiologic Classification, Imaging, and Molecular Characterization of Diagnosed Children in 2005-2015
Aura Funez1, María Eugenia Lara1, Ana Cecilia Chévez1, Efrén Castellón2, Josefa Toro3, Eladio Montoya3, and José Carlos Moreno4
1Universidad Nacional Autónoma de Nicaragua, León, León, Nicaragua
2Universidad de Alcalá, Alcalá de Henares, León, Nicaragua
3Universidad de Alcalá, Alcalá de Henares, Madrid, Spain
4Hospital Universitario La Paz, Universidad Autónoma de Madrid, Madrid, Spain
094 - The Inclusion of ADA SCID in Expanded Newborn Screening by Tandem-Mass Spectrometry
Giancarlo La Marca, Maria Dalla Bona, Fabio Villanelli, Francesca Romano, Elisabetta Pasquini, Sabrina Malvagia, Silvia Funghini, Massimo Resti, and Chiara Azzari
University of Florence, Meyer Children’s University Hospital, Firenze, Italy
Adenosine deaminase (ADA) deficiency is an inherited disorder that causes severe combined immunodeficiency (SCID). The early-onset form is rapidly fatal in infancy because of severe infections. Patients with delayed or late-onset form suffer of multiple recurrent infections that may lead to permanent organ damage or death in childhood or adulthood. Irreversible brain damage may have already occurred before diagnosis is done. Gene therapy, bone marrow transplantation, or enzyme therapy might be effective if performed early. ADA-SCID meets the criteria for inclusion in newborn screening (NBS) program. The quantification of T cell receptor excision circles (TRECs) generated during maturation of T cells can identify newborns with early-onset ADA SCID on dried blood spots (DBS) collected at birth. In 2011, our group reported elevated level of adenosine (Ado) and 2-deoxyadenosine (dAdo) in DBS from newborns with ADA SCID early onset by tandem-MS analysis. However, it was not clear whether patients with delayed or late-onset form can be identified at birth before symptoms appear. Since 2011, we tested ADA metabolites in the our NBS panel, identifying an ADA affected newborn. Patient was confirmed by genetic testing as delay/ late onset ADA SCID. She had normal TREC levels. For this reason, the neonatal DBS from other 8 patients with delayed or late onset ADA-SCID were retrospectively analyzed by tandem-MS to evaluate levels of Ado and dAdo, and TREC levels were quantified by real-time PCR. All patients showed adenosine values between 1.08- 25 µmol/L (n.v. <2) and 2-deoxyadenosine values between 0.11-2.7 µmol/L (n.v. <0.1) with ratio Ado/dAdo >2.2. Finally, all 8 patients had undetectable or low TREC levels at the diagnosis but normal TREC test on neonatal DBS. We also analyzed DBSs from 21 newborns with early-onset form showing Ado levels between 0.15 and 47.2 µmol/L (n.v. <2) and dAdo values between 0.46 and 55.7 µmol/L (n.v <0.1) with ratio Ado/dAdo <2.2. In this study, we report how ADA SCID patients can be identified at birth measuring biomarker levels by tandem-MS. In addition, Tandem-MS assay allows an easy inclusion of ADA SCID markers within the expanded newborn screening panel, worldwide performed. Most recently, we have validated a new tandem-MS test for the inclusion of Purine Nucleoside Phosphorylase deficiency, another SCID suitable for NBS by mass spectrometry.
095 - Additional Diagnoses Coming to Attention via Newborn Screening for Phenylalanine Hydroxylase and Biotinidase Deficiencies
Ayşegül Tokatli, Yilmaz Yildiz, M. Şenol Akin, Ozlem Saritaş Nakip, Emine Goksoy, Berrak Bilginer Gurbuz, Ali Dursun, Serap Sivri, and Turgay Coskun
Hacettepe University, Ankara, Turkey
In Turkey, a country with a population of approximately 80 million, nearly 1.5 million babies are born every year. Currently, phenylalanine hydroxylase (PAH) deficiency and biotinidase deficiency are the 2 inborn errors of metabolism in the newborn screening (NBS) program, which has a coverage rate of 99.8%. In this retrospective study, we evaluated the infants referred to a major metabolic center in Turkey in 2016 due to positive NBS for one of these two disorders, who received additional or unrelated diagnoses as a result of follow-up after NBS. A total of 371 infants were referred in 2016 due to suspicion of PAH or biotinidase deficiency. Among 232 infants with elevated phenylalanine (Phe) in NBS, 98 were found to have normal Phe, 121 had mild hyperphenylalaninemia not requiring treatment, and 13 received treatment for phenylketonuria (PKU). Of the 139 infants referred for suspicion of biotinidase deficiency, 40 had normal biotinidase activity and 99 were started on biotin treatment. 8 infants (2.16%) received additional diagnoses as a result of physical and laboratory examinations with one case each of classical galactosemia, I-cell disease, hypertriglyceridemia, citrin deficiency, acute lymphoblastic leukemia, Down syndrome, severe acute malnutrition, and spinal muscular atrophy (SMA) type I. Six of these infants were given specific treatment for their conditions. Only 1 of the 8 infants was diagnosed with the condition that was suspected in NBS. (Patient with SMA also had PKU.) Only galactosemia and citrin deficiency had been previously associated with transient hyperphenylalaninemia. Infants with false-positive NBS results are commonly disregarded in clinics and discharged without even a physical examination. This study underlines the importance of history taking and physical examination in every newborn a physician encounters. Diagnosis in most, if not all, of these infants would have been delayed or missed had a thorough physical examination not been performed. Metabolic physicians should consider assessing all infants referred from NBS for possible unrelated or comorbid medical conditions regardless of the outcome of metabolic work-up.
096 - Tierra del Fuego, Antarctica, and South Atlantic Islands: Analysis of the Newborn screening program (1996-2016)
Carolina Yulán1, Gustavo Dratler2, Carlos Lopéz1, Artieda Horacio1, Silvana Cáceres1, Roberto Moreyra1, Gisella Di Pietro3, Ivan Gramundi1, and Javier Campero1
1Hospital Regional Ushuaia Gobernador Ernesto Campos, Ushuaia, Argentina
2Laboratorio de Pesquisa Neonatal- Hospital de Pediatria Samic Dr Jp Garrahan, Buenos Aires, Argentina
3Hospital Regional Río Grande Nuestra Sra de La Candelaria, Río Grande, Argentina
097 - Flow Injection Analysis—A Novel Approach for the Second-Tier Estimation of Methylmalonic Acid on Dried Blood Spot to Improve Newborn Screening for Methylmalonic Aciduria
Bijo Varughese, Somesh Kumar, Sunil Kumar Polipalli, and Seema Kapoor
Pediatric Research and Genetic Lab, Department of Pediatrics, Maulana Azad Medical College, New Delhi, India
098 - High Prevalence of Congenital Adrenal Hyperplasia in the Southeast Mexico
Mercedes-Beatriz Medina-Aguilar1, Silvina-Noemi Contreras-Capetillo1, Felix-Julian Campos-Garcia2, Luz-Del-Alba Herrera-Perez2, Claudia Moreno-Graciano2, Patricia Martinez-Cruz2, Felipe-Angel Maldonado-Solis2, and Carlos Eduardo Arias Vidal2
1“Dr. Agustin O’Horán” General Hospital, Yucatán, México, Mérida, Mexico
2Tamizaje Plus Sa de Cv (Tamizmas), Yucatán, México., Mérida, Mexico
099 - Potential Cost-Effectiveness of Including Screening for X-linked Adrenoleukodystrophy in the UK National Health Service Newborn Blood Spot Screening Program
James Chilcott, Alice Bessey, Joanna Leaviss, and Anthea Sutton
University of Sheffield, Sheffield, United Kingdom
100 - A Strategy With an Integrative Approach Reinforces Congenital Defect Surveillance in Paraguay
Marta Ascurra1, Cynthia Benitez1, Pamela Alvarez2, and Margarita Samudio3
1Programa Nacional de Detección Neonatal. Ministerio de Salud Pública Y Bienestar Social, Asunción, Paraguay
2Programa Nacional de Deteccción Neonatal. Ministerio de Salud Pública Y Bienestar Social, Asunción, Paraguay
3Instituto de Investigaciones En Ciencias de La Salud. Universidad Nacional de Asunción, Asunción, Paraguay
101 - Congenital Adrenal Hyperplasia Neonatal Screening in Southern Brazil: The Challenges Until Confirmatory Diagnosis
Simone Martins de Castro1, Cláudia Maria Dornelles da Silva2, Mayara Prado3, Tarciana Grandi2, Luciana Beltrão4, Marta Chapper4, Maria Lucia Rosa Rossetti2, Paula Vargas4, and Cristiane Kopacek4
1Hospital Materno Infantil Presidente Vargas-Pmpa/Ufrgs, Porto Alegre, RS, Brazil
2Centro de Desenvolvimento Científico e Tecnológico/Ses, Porto Alegre, RS, Brazil
3Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
4Hospital Materno Infantil Presidente Vargas-Pmpa, Porto Alegre, RS, Brazil
Congenital adrenal hyperplasia (CAH) occurs due to enzymatic defects in adrenal steroidogenesis. The 21-hydroxylase enzyme deficiency accounts for 90% to 95% of the cases, triggering accumulation of 17-hydroxyprogesterone (17-OHP). Early diagnosis through neonatal screening (NS) allows adequate treatment and reduction of mortality. Genotype diagnosis is an important confirmatory tool and helps to establish the severity of the disease in confirmed cases and, also help to differentiate false positives from milder forms of the disease.
102 - Challenges in Neonatal Diagnosis of Cystic Fibrosis: 4 Years of Experience in Southern Brazil
Simone Martins de Castro1, Helena Mocelin2, Gilberto Fischer2, Cláudia Maria Dornelles da Silva3, Grazielle Rodrigues4, Tarciana Grandi3, Marta Chapper2, and Thaiane Rispoli Serrano4
1Hospital Materno Infantil Presidente Vargas-Pmpa/Ufrgs, Porto Alegre, RS, Brazil
2Hospital Materno Infantil Presidente Vargas-Pmpa, Porto Alegre, RS, Brazil
3Centro de Desenvolvimento Científico e Tecnológico/Ses, Porto Alegre, RS, Brazil
4Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
103 - Newborn Screening for Inborn Errors of Metabolism by Tandem Mass Spectrometry in Costa Rica: 11 Years of Experience
Alejandra Reuben1, Natassia Camacho1, Joaquín Hidalgo1, Danny Alvarado1, Jonessy Quesada2, Ramsés Badilla-Porras2, Jorge Delgado2, Mildred Jiménez-Hernández1, and Manuel Saborio2
1Laboratorio Nacional de Tamizaje Neonatal Y Alto Riesgo, San José, Costa Rica
2Servicio de Genética Médica Y Metabolismo, Hospital Nacional de Niños, San José, Costa Rica
104 - Evaluation of Quality Indicators of The National Newborn Screening Program in Costa Rica (2014 to 2016)
Sergio Obando1, Mildred Jiménez-Hernández1, and Manuel Saborio2
1Laboratorio Nacional de Tamizaje Neonatal Y Alto Riesgo, San José, Costa Rica
2Servicio de Genética Médica Y Metabolismo, Hospital Nacional de Niños, San José, Costa Rica
105 - Korle-Bu and Osu Christiansborg Hemoglobin Variants Detected in Costa Rican National Newborn Screening Program (2015-2016)
María Gabriela Abarca1, Danny Alvarado1, Indira Chaves1, Mildred Jiménez-Hernández1, and Manuel Saborio2
1Laboratorio Nacional de Tamizaje Neonatal Y Alto Riesgo, San José, Costa Rica
2Servicio de Genética Médica Y Metabolismo, Hospital Nacional de Niños, San José, Costa Rica
106 - Establishing Validity of Reference Range Concentrations of Acylcarnitine Species by Tandem Mass Spectrometry in a Cohort of Heathy Neonates in South India: A Pilot Study
Anna Simon and Sophy Korula
Christian Medical College, Vellore, Tamil Nadu, India
107-Molecular Diagnosis for Target Metabolic Diseases of Newborn Screening Using a Gene Panel in Japan
Hideo Sasai1, Hiroki Otsuka1, Ryoji Fujiki2, Osamu Ohara2, Yoko Nakajima3, Tetsuya Ito3, Masahisa Kobayashi4, Go Tajima5, Osamu Sakamoto6, Shirou Matsumoto7, Kimitoshi Nakamura7, Takashi Hamazaki8, Hironori Kobayashi9, Yuki Hasegawa9, and Toshiyuki Fukao1
1Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
2Department of Technology Development, Kazusa Dna Research Institute, Kisarazu, Japan
3Department of Pediatrics, Fujita Health University School of Medicine, Toyoake, Japan
4Department of Pediatrics, The Jikei University School of Medicine, Tokyo, Japan
5Division of Neonatal Screening, Research Institute, National Center for Child Health and Development, Tokyo, Japan
6Department of Pediatrics, Tohoku University Graduate School of Medicine, Sendai, Japan
7Department of Pediatrics, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
8Department of Pediatrics, Osaka City University Graduate School of Medicine, Osaka, Japan
9Department of Pediatrics, Shimane University Faculty of Medicine, Izumo, Japan
108 - Newborn Screening for Hemoglobinopathies in the Public Health System in Southern Brazil From 2004 to 2016
Simone Martins de Castro1, Tarciana Grandi2, Vera Diedrich3, and Juliana Macedo3
1Hospital Materno Infantil Presidente Vargas-Pmpa/Ufrgs, Porto Alegre, RS, Brazil
2Centro de Desenvolvimento Científico e Tecnológico/Ses, Porto Alegre, RS, Brazil
3Hospital Materno Infantil Presidente Vargas/Pmpa, Porto Alegre, RS, Brazil
109 - 10 Years of Expanded Newborn Screening Program on Southeastern Spain: Impact on Clinical Outcome of Inborn Errors of Metabolism
David Gil Ortega, Maria Jesús Juan-Fita, José María Egea Mellado, Inmaculada Vives Piñera, and Inmaculada González Gallego
Metabolic Unit, Hosp Universitario Virgen de La Arrixaca, Murcia, Spain
110 - What Are the Perspectives of Families Who Have Child With Organic Acidemia or Phenylketonuria to Prenatal Diagnosis in Subsequent Pregnancies?
Turgay Coskun1, Berrak Bilginer Gurbuz1, Melek Buyukeren2, Emine Aydin3, Hasan Tolga Çelik2, and Sinan Beksac3
1Hacettepe University, Pediatric Metabolism, Ankara, Turkey
2Hacettepe University, Neonatology, Ankara, Turkey
3Hacettepe University, Gynecology, Ankara, Turkey
111 - Molecular Biology Laboratory as an Important Support in the Final Diagnosis of the Diseases Triaged in Newborn Screening in Southern Brazil
Simone Martins de Castro1, Thaiane Rispoli Serrano2, Mayara Prado2, Tarciana Grandi3, Cláudia Maria Dornelles da Silva3, Grazielle Rodrigues2, Helena Mocelin4, Gilberto Fischer4, Marta Chapper4, Juliana Macedo4, and Cristiane Kopacek4
1Hospital Materno Infantil Presidente Vargas-Pmpa/Ufrgs, Porto Alegre, RS, Brazil
2Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
3Centro de Desenvolvimento Científico e Tecnológico/Ses, Porto Alegre, RS, Brazil
4Hospital Materno Infantil Presidente Vargas-Pmpa, Porto Alegre, RS, Brazil
Newborn screening (NBS) is an important public health program. Correct planning and an institutional structure that includes qualified professionals, as well as a broad articulation and cooperation among institutions, are fundamental to the efficiency of a NBS program. Molecular studies increase diagnostic efficacy and allow epidemiological and population data.
112 - Neonatal Screening for Biotinidase Deficiency: Experience of the First Six Years in the State of Santa Catarina
Louise Pinto, Bruna Zago, Camila Coan, Francisca Ligia Carvalho, Gisele Luca, and Jose Goes
Hospital Infantil Joana de Gusmao, Florianopolis, SC, Brazil
113-Newborn Screening for Galactosemia: Experience of the First Six Years in the State of Santa Catarina
Louise Pinto, Camila Coan, Bruna Zago, Francisca Ligia Carvalho, Gisele Luca, and Jose Goes
Hospital Infantil Joana de Gusmao, Florianopolis, SC, Brazil
114 - Prevalence of Congenital Hypothyroidism During the Years 2007 to 2016, in Arauca, Colombia
H. Alix Robinson
Special Administrative Unit of Health of Arauca (Colombia), Arauca, Colombia
115 - Prevalence of Metabolopathies and Hemoglobinopathies, Identified in the Health Services of the Mexican Armed Forces From May 2012 to July 2016
Oliver de La Torre García1, Ramon Salgado-Sangri1, Roberto Mar-Aldana1, Jesus Benitez-Granados2, Emmanuel Melgarejo-Estefan3, Luz Del Alba Herrera Pérez4, Patricia Martinez-Cruz4, Silvia Loo-Salome5, Jorge Valencia-Moncada5, Luis Bonilla-Arcuate5, Liliana Teran-Montiel6, and Luis Madrigal-Mendoza6
1Hospital General Naval de Alta Especialidad de La Secretaría de Marina Armada de México, Mexico, Mexico
2Facultad de Medicina Cu Unam, Mexico, Mexico
3Facultad de Ciencias de La Salud, Universidad Anahuac, Mexico, Mexico
4Laboratorios Tamizmas de Químicos Maldonado, Merida, Mexico
5Dirección General Adjunta de Sanidad Naval, Secretaría de Marina Armada de México, Mexico, Mexico
6Sección de Salud Pública de La Secretaría de La Defensa Nacional, Mexico, Mexico
116 - 14 Years of Newborn Screening Program for Congenital Hypothyroidism in the Instituto Nacional Materno Perinatal, Lima-Peru
Rina Ruth Zumaeta Beramendi
Instituto Nacional Materno Perinatal, Lima, Peru
117- Evaluation of Neonatal CF Research Strategies in the Province of Santa Fe. 21 Years of Experience
Laura Graciela Maggi
Ministerio de Salud Provincia de Santa Fe, Argentina, Santa Fe, Argentina
118 - Evaluation of Homogeneity of Control Materials for Phenylalanine and TSH in Dried Blood Spots
Gustavo Borrajo and Maria Jose Parente
Fundacion Bioquimica Argentina, La Plata, Argentina
119 - Neonatal Thyroid Stimulating Hormone: Introducing a Critical Cutoff to Improve Laboratory Services
Hafsa Majid, Hussain Karimi, Lena Jafri, and Aysha Habib Khan
Aga Khan University Hospital, Karachi, Pakistan
120 - 17 Years of Experience of Newborn Screening Program: Mendoza, Argentina
Ana Guercio1, Samanta Bassino1, Belen Castro1, Veronica Lobato1, Agustin Vergara1, Natalia Carminati1, Laura Verdaguer1, Elsa Ayub1, Marcela Pereyra2, and Ana Lores3
1Programa Prov. de Pesquisa Neonatal-Ce.P.E.I.I. Hospital Pediatrico Dr. Humberto J. Notti, Mendoza, Argentina
2Servicio de Crecimiento Y Desarrollo. Hospital Pediatrico Dr. Humberto J. Notti, Mendoza, Argentina
3Programa Prov. de Fibrosis Quistica. Hospital Pediatrico Dr. Humberto J. Notti, Mendoza, Argentina
121 - Evaluation of IRT/IRT Strategy for Cystic Fibrosis Early Detection in a Hospital of High Complexity, Mendoza Argentina
Ana Guercio, Samanta Bassino, Belen Castro, Veronica Lobato, Agustin Vergara, and Natalia Carminati
Programa Prov. de Pesquisa Neonatal-Ce.P.E.I.I. Hospital Pediatrico Dr. Humberto J. Notti, Mendoza, Argentina
122 - High Incidence of Congenital Hypothyroidism in the State of Yucatan, Mexico
Mercedes-Beatriz Medina-Aguilar1, Silvina-Noemi Contreras-Capetillo1, Luz Del Alba Herrera Pérez2, Claudia Moreno-Graciano2, Patricia Martinez-Cruz2, Felipe Angel Maldonado Solis2, Mario Arturo Maldonado Solis2, and Carlos Eduardo Arias Vidal2
1“Dr. Agustin O’Horán” General Hospital, Merida, Mexico
2Tamizmas, Tamiz Ampliado de Yucatán S.A. de C.V., Mérida, Mexico
123 - National Newborn Screening Program for a Better Indonesia
Ina S Timan1, Rina Rohsiswanto2, Damayanti Rusli Sjarif2, and Merci Monica1
1Faculty of Medicine, Department of Clinical Pathology, University of Medicine, Jakarta, Indonesia
2Faculty of Medicine, Child Health Department, University of Indonesia, Jakarta, Indonesia
Screening program for newborn screening in Indonesia started in 2000 as a pilot project exclusively for Congenital Hypothyroidism. The program was partially funded by IAEA, but the lack of support and interest on the program made it short lived and was not adopted as a national program. Since 2012, however, with a growing interest from medical practitioners for a better diagnosis and treatment of metabolic disorders on newborns, the Ministry of Health started a National program for Congenital Hypothyroidism in Indonesia.
124 - Newborn Screening for Fabry Disease in Tuscany and Umbria: Importance of Family Studies
Elisabetta Pasquini, Giancarlo La Marca, Amelia Morrone, Marta Daniotti, Giulia Forni, Lorenzo Ferri, Duccio Malesci, Sabrina Malvagia, Silvia Funghini, Emanuela Scolamiero, and Maria Alice Donati
Meyer Children's Hospital, Florence, Italy
125 - Newborn Screening for Methylmalonic Acidemias in Emilia-Romagna (Italy): A 4-Year Study
Federico Baronio1, Rita Ortolano1, Ilaria Bettocchi1, Francesca Righetti1, Alessandra Vitali1, Amelia Morrone2, Catia Cavicchi3, Lorenzo Ferri3, Andrea Pession1, and Alessandra Cassio1
1Department of Woman, Child and Urologic Diseases, Aou S.Orsola-Malpighi, University of Bologna, Bologna, Italy
2Meyer Children’s Hospital and Department of Neurofarba, University of Florence, Florence, Italy
3Meyer Children’s Hospital, Florence, Italy
126 - Total Parenteral Nutrition Effect on Maple Syrup Urine Disease Newborn Screening Recall Rate
María Laura Sueiro, Federico José Torres, Mercedes Hunt, Claudio Ariel Castillo, Adriana Oneto, Hernán Eiroa, Ana Chiesa, Gladys Guarrera, Gustavo Maccallini, and Claudio Aranda
Newborn Screening Program, Hospital Carlos G. Durand, Buenos Aires, Argentina
127 - Spectrum of Metabolic Disorders via Expanded Newborn Screening by MSMS at a Tertiary Healthcare Centre of North India
Somesh Kumar1, B. K. Thelma2, Somesh Kumar1, Bijo Varughese1, Avinash Lomash1, and Virendra Upadhayay3
1Maulana Azad Medical College, New Delhi, India
2Department of Genetics, South Campus, University of Delhi, New Delhi, India
3Lipomic Health Care Pvt. Ltd, New Delhi, India
128 - 6-Pyruvoyl-Tetrahydropterin Synthase Deficiency in Mexico: A Call to Action
Marcela Vela-Amieva1, Cynthia Fernandez-Lainez2, Isabel Ibarra-Gonzalez3, Ariadna Gonzalez-Del Angel1, Miguel Angel Alcantara-Ortigoza1, Sara Guillén López1, Liliana Fernandez-Hernandez1, Leticia Belmont-Martinez2, and Lizbeth Lopez-Mejia2
1Instituto Nacional de Pediatría, Mexico, Mexico
2Instituto Nacional de Pediatria, Mexico, Mexico
3Unidad de Genética de La Nutrición, Instituto de Investigaciones Biomédicas, Unam, Mexico, Mexico
6-Pyruvoyl-tetrahydropterin synthase (PTPS) is involved in BH4 de novo biosynthesis, and its deficiency (PTPSD, MIM *612719) is characterized by hyperphenylalaninemia and deficit of central monoamine neurotransmitters. It is widely known that neonatal differential diagnosis of hyperphenylalaninemia should include pterin profile determination in order to discard defects on BH4 metabolism. Herein we describe the clinical characteristics and mutational spectrum of PTPSD patients, as well as the difficulties for their diagnosis and treatment in an underdeveloped country.
129-Establishment and Clinical Validation of a Cutoff Value for Newborn Screening for Isovaleric Acidemia and Glutaric Acidemia Type 1
María Laura Sueiro, Federico José Torres, Mercedes Hunt, Claudio Ariel Castillo, Adriana Oneto, Hernán Eiroa, Ana Chiesa, Gladys Guarrera, Gustavo Maccallini, and Claudio Aranda
Newborn Screening Program, Hospital Carlos G. Durand, Buenos Aires, Argentina
130 - Impact of the Use of the SUMA Technology in the Program of Congenital Hypothyroidism in the Colombian Health System
Patricia Muñoz Ibarra1, Jorge Francisco Gentile2, Roberto Guilarte3, Gustavo Frías3, Leon Dovale3, and Tania Licourt3
1Tecnosuma Internacional S.A. Sucursal Colombia, Bogotá, Colombia
2Tecnosuma Internacional S.A. Sucursal Colombia, Bogota, Colombia
3Centro de Inmnunoensayo, La Habana, Cuba
131 - Seven-Plex MS/MS Method to Measure I2 S, NAGLU, GALNS, GLB1, ARSB, GUSB, and TPP1 Enzyme Activities in DBS
Anna Potier1, Jonathan Rehnberg2, Joe Trometer1, Sricharan Bandhakavi1, Sara Smith3, James Diperna3, Naveen Kumar Chennamaneni4, and Gelb4
1Perkinelmer, Waltham, MA, USA
2Perkinelmer, Turku, Finland
3Perkinelmer, Bridgeville, DE, USA
4University of Washington, Seattle, WA, USA
The mucopolysaccharidoses (MPS) family of lysosomal storage disorders (LSDs) is caused by defects in the metabolic breakdown of glycosaminoglycans (GAGs). This work demonstrates a novel MS/MS assay that simultaneously monitors the activity of seven different MPS enzymes. Using a single 3.2 mm dried blood spot (DBS) punch and incubation cocktail, our assay has the ability to identify samples with low enzyme activities for I2 S (MPS II), NAGLU (MPS IIIB), GALNS (MPS IVA), GLB1 (MPS IVB), ARSB (MPS VI), GUSB (MPS VII), and TPP1 (CLN2). The seven-plex is incubated overnight in the presence of incubation cocktail at 37°C followed by a post-incubation, fully automated workup that is less than 30 minutes per plate. Sample-to-sample time using MS/MS analysis can be as low as 2 minutes, which allows the possibility to obtain more than 5000 results per day if desired. Method performance studies show good linearity for each enzyme in their respective activity range. Furthermore, a study consisting of several hundred presumed healthy neonates, confirmed low I2S/NAGLU/GALNS/GLB1/ARSB/GUSB/TPP1 activity and CDC control DBS showed excellent resolution and clear distinctions between the different enzyme activity levels.
132 - Glutaric Aciduria Type-I Missed by Newborn Screening: Report of Three Cases
Ralph Fingerhut1, Johannes Spenger2, Katharina Portmann3, Florian Bauder3, Melanie Kocher3, Wolfgang Sperl2, Martin Preisel2, Johannes HaüBerle4, Thomas Schmitt-Mechelke3, and Saskia Wortmann2
1Newborn Screening Laboratory, Division of Metabolism and Children’s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
2Department of Pediatrics, Salzburger Landeskliniken (Salk) And Paracelsus Medical University (PMU), Salzburg, Austria
3Children’s Hospital Luzern, Luzern, Switzerland
4Division of Metabolism and Children’s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
133 - Training Courses and Update for Primary Health Care Professionals
Michelle Rosa Andrade Alves, Isabel Pimenta Spínola Castro, Viviane de Cássia Kanufre, Graziela Maria Souza, Raissa Hilda Celestina Azevedo, Cláudia Soares do Couto Macedo, Soraia Miranda Cabral, Giovanna Caliman Camatta, and Alexandra Amélia de Deus
Center for Action and Research in Support Diagnostics (Nupad), Belo Horizonte, MG, Brazil
134 - Pilot Newborn Screening Program for Treatable Lysosomal Diseases in Brazil: Study Design for Biochemical Diagnosis
Fernanda Bender1, Maira Burin2, Heydy V. Bravo Villalta1, Gabriel Civallero2, and Roberto Giugliani2
1Ufrgs, Porto Alegre, RS, Brazil
2Hcpa, Porto Alegre, RS, Brazil
Lysosomal storage disorders (LSDs) are inherited conditions usually caused by a deficiency in a specific lysosomal enzyme. This deficiency usually causes the storage of substrates, leading to a progressive and most times severe problems in many organs and systems. Most LSDs are inherited in an autosomal recessive manner, with few exceptions which are X-linked. At present, there is no cure for LSDs. Today, bone marrow transplantation (BMT) and mainly enzyme replacement therapy (ERT) are the usually available treatment options for patients with selected LSDs. As some LSDs can be treated and as there is evidence that a better result can be expected in cases treated early, a program of neonatal screening is being considered for these diseases. Enzyme assays for Gaucher, Fabry, Pompe, MPS I, MPS II, and MPS VI, and also quitotriosidase as potential biomarker were added to the standard screening panel (phenylketonuria, congenital hypothyroidism, hemoglobin disorders, cystic fibrosis, biotinidase deficiency and congenital adrenal hyperplasia). This project, in its first stage, adapted the standard fluorometric enzyme assays to micromethods, reducing the cost of reagents and mainly of the specific expensive substrates. In the second step, the study is evaluating operational issues (feasibility, costs, false-positive rate, and other aspects) related to the inclusion of the lysosomal panel in the newborn screening program and provide valuable information to the newborn screening operators in Brazil.
135 - Reproductive Options, a Secondary Benefit of Newborn Screening (NBS) for X-Linked Adrenoleukodystrophy (X-ALD): A Model and Lessons From the New York State NBS Program at a Single Institution
Alejandro Iglesias
Columbia University Medical Center, New York, USA
On January 1, 2014, NYS started NBS for X-ALD. All confirmed cases are followed using a protocol (published somewhere) including neurology and endocrinology exams and imaging (brain MRI) and labs (C26:0, endocrine). According to the protocol confirmatory testing includes the proband and the mother. If the mother is positive, testing other siblings is then discussed. After confirmation, the mother and the siblings are enrolled in the protocol. For male siblings, brain MRIs with contrast and the possibility of the use of Lorenzo’s oil are considered. A search for a compatible BMT/HSCT donor is also addressed. A secondary benefit of the NBS has emerged as discussing reproductive options. Few instances of prenatal testing have been published and all were known familial cases. Conversely, since NBS is new no information is available. Hence, we are proposing a model to address reproductive options to reduce recurrence risk. A discussion about X-linked inheritance, risk of transmission, different risks if the transmitting parent is a male or female, and if the affected proband is male or female are discussed. Strategies for risk reduction or management include not to have children, adoption, egg or sperm donor, prenatal diagnosis, and no intervention. For prenatal diagnosis, the techniques discuss include chorionic villous sampling, amniocentesis, and preimplantation genetic diagnosis. For each of them, the degree of reduction varies and is addressed. At our institution, we have used the model in 3 families since NBS started. Family 1 was found to have a newborn, his older brother, and their mother affected. Family 2 has an infant and his mother affected. Family 3 was found to have a newborn, an older brother and their mother, all affected. All affected family members are currently follow according protocol. For family 1 and 2 reproductive options have been discussed. Family 1 has opted not to have more children. Family 2 is considering further children, but no decision has been taken yet. Family 3, so far, has not considered to have a discussion about reproductive issues. In conclusion, although NBS has recently started and the experience is short, at our center we have implemented a model to discuss reproductive options that seems to be effective. Further cases, longer follow-up and share experience from other centers will give more input into the validity of this model in the context of NBS for X-ALD
136 - Molecular studies in patients with Congenital Adrenal Hyperplasia in Newborn Screening Service
Vitor de Araújo1, Kallianna Gameleira2, Ana Beatriz Fabrício de Melo1, Larissa Bruna de Brito Toledo1, Karine Santielle Pereira Malheiros2, and Adriana Lofrano Alves Porto3
1Laboratório de Triagem Neonatal, Unidade de Genética, Hospital de Apoio de Brasília, Brasília, DF, Brazil
2Unidade de Genética, Hospital de Apoio de Brasília, Secretaria de Estado de Saúde do Distrito Federal, Brasília, DF, Brazil
3Laboratório de Farmacologia Molecular, Faculdade de Ciências da Saúde, Universidade de Brasília, Brasília, DF, Brazil
137 - Comparative Study Between Three Methods of Analysis in Newborn Screening for Hemoglobinopathies
Heloise Martins1, Sônia Hadachi1, Andre Daneluzzi D’Ambrosio2, Cibele Aguiar1, Luciana Ruano Gaspar Garcia1, Maricene Magon Iskandar1, and Gisele Balieiro1
1Associação de Pais e Amigos dos Excepcionais de São Paulo, São Paulo, SP, Brazil
2Faculdade de Engenharia de Guaratinguetá, São Paulo, SP, Brazil
The diagnosis of hemoglobinopathies is based on the separation of fractions of hemoglobin (Hb). The most common conventional methodologies used in Newborn Screening (NS) are isoelectric focusing (IEF), high performance liquid chromatography (HPLC), and capillary electrophoresis (CE). These methods can be used alone or in case of positive or doubtful results can be associated for better sensitivity and specificity. Among other methodologies, in the last decades the HPLC method has provided an automated and robust method with fast identification of the Hb, used in many laboratories of NS around the world. Recently, the Primus Ultra2 Genesys (Trinity Biotech) equipment was introduced in to the market, with fast and accurate analyses using two types of assay in HPLC method: the fast screening program (HPLC-Quick), and the High Resolution (HPLC-High) used to confirm the results. The objective of this study was to analyze and compare three methods, HPLC (Primus Ultra2 Genesys - Trinity Biotech), EC (Capillary Neonat Hemoglobin) and IEF (Perkin Elmer) in the routine of NS for hemoglobinopathies in the Laboratory of APAE DE SÃO PAULO. In this study, were randomly selected 258 samples of dry blood in filter paper from laboratory routine for analysis in all these three methods. Comparing the HPLC-Quick and EC methods with the IEF data, we obtained a great correspondence for both methods, regarding the normal Hb (FA / AF / AA) pattern, that is, of the 63 hemoglobins detected by the IEF, 80.95% to 95.24% presented the same result in HPLC-High and HPLC-Quick. The hypothesis test between the EC, HPLC - High and Quick methods for Hbs F, A, S and C showed values of P <.001. Considering the results obtained, we found that the HPLC-High method presents a larger diagnostic range, it can be considered a more precise method and its better use for the detection of variant Hbs. Based on the EC method, the HPLC-High and HPLC-Quick methods were more accurate than the latter, although they showed good correlation between methods.
138 - International Collaborative Newborn Screening Pilot Program
Gabriel de Jesus Silva1, Maria Lucia Silva Polanco2, Ralph Fingerhut3, Maria Antonieta Sandoval4, and Victoria Helen Leal Navas1
1Universidad de San Carlos de Guatemala, Guatemala, Guatemala
2Obras Sociales Del Santo Hermano Pedro, Antigua Guatemala, Guatemala
3Newborn Screening Laboratory, Children’s Research Centre, University Children’s Hospital, Zurich, Switzerland
4Obras Sociales Del Santo Hermano Pedro, Guatemala, Guatemala
139 - Alleatory Screening for Aminoacidopathyes and Disorders in Acyl Carnitines in a Newborn Population from Guatemala
Maria Sandoval, María Silva, and Gabriel de Jesus Silva
Obras Sociales Del Santo Hermano Pedro, Guatemala, Guatemala
140 - Clinical Profile and Outcomes of Individuals With Elevated Methylmalonylcarnitine/Hydroxyisovalerylcarnitine Ratio in Newborn Screening Test
Romina Soledad Heredia Garcia Silva, Ana Carolina Rathsam Leite, Gabrielle Roos Diel, Carina Lassance de Albuquerque, Alice Aguiar Crispim, Karine Santielle Pereira Malheiros, Jeanne Mazza, Kallianna Gameleira, Bárbara Cátia Martins, Monique Poubel, Maria Teresinha Oliveira Cardoso, Maria Teresa Alves da Silva Rosa, and Graziela Paronetto Machado Antonialli
Ses-Df, Brasília, DF, Brazil
Tandem mass spectroscopy (MS/MS) was first instituted in the public newborn screening (NBS) test in Brazil in 2010, in the Federal District, as a result of state’s legislation. From a single bloodspot, this method enables the early detection of more than 20 inborn errors of metabolism, particularly organic acidemias, amino acid and fatty acid oxidation disorders. One of the advantages of MS/MS is that allows the detection of a large number of analytes in a single assay. Meanwhile primary analytes are well established for a number of diseases, secondary analytes are utilized to improve sensitivity and tend to vary between programs, since the selection of both is dependent on the preference of the individual NBS program. One of these optional analytes is the methylmalonylcarnitine–hydroxyisovalerylcarnitine ratio (C4DC/C5OH) that may be abnormal in several organic acidemias.
141 - Clinical Outcomes of Individuals with Hypergalactosemia in Newborn Screening Test Accompanied in the Public Health System in the Federal District, Brazil
Graziela Paronetto Machado Antonialli1, Anna Karolinne Nascimento2, Karine Santielle Pereira Malheiros1, Jeanne Mazza1, Kallianna Gameleira1, Bárbara Cátia Martins1, Monique Poubel1, Maria Teresa Alves da Silva Rosa1, Maria Teresinha Oliveira Cardoso1, and Romina Soledad Heredia Garcia Silva1
1Ses-Df, Brasília, DF, Brazil
2Universidade Católica de Brasília, Brasília, DF, Brazil
Galactosemia is a genetic disorder due to deficiency in one of three enzymes related to galactose metabolism: galactose-1-phosphate uridylyl transferase (GALT), galactokinase, and galactose epimerase. The most prevalent forms of galactosemia are those related to GALT deficiency and can be classified as classic galactosemia, clinical and biochemical variant galactosemia. Classic galactosemia, if untreated, can be a life-threatening disease characterized by feeding difficult, failure-to-thrive, hepatic damage, bleeding, and E. coli sepsis. Newborn Screening test (NBST) for galactosemia is available in the Public Health System in the Federal District (SES-DF), Brazil, since 2012.
142 - Tandem Mass Spectroscopy Profile in Newborn Screening Test of Premature Brazilian Patients of the Federal District and Their Clinical Outcome
Ana Carolina Rathsam1, Alice Crispim1, Anna Karolinne Nascimento2, Gabrielle Diel1, Carina Albuquerque1, Karine Santielle Pereira Malheiros3, Bárbara Cátia Martins3, Monique Poubel3, Maria Teresinha Cardoso3, Jeanne Mazza3, Kallianna Gameleira3, Maria Teresa Rosa3, Romina Soledad Heredia Garcia Silva3, and Graziela Paronetto Machado Antonialli3
1Hospital de Base do Distrito Federal, Brasília, DF, Brazil
2Universidade Católica de Brasília, Brasília, DF, Brazil
3Hospital de Apoio do Distrito Federal, Brasília, DF, Brazil
Newborn Screening (NBS) is recognized as an important population health initiative, involving the systematic testing of asymptomatic individuals for a specific condition to detect early stages of inborn errors of metabolism (IEM) and other congenital disorders. The NBS service of Federal District is a pioneer in performing the expanded screening test using Tandem Mass Spectroscopy (MS/MS) technology in Public Health Service in Brazil. One abnormal finding in MS/MS can be translated into several different metabolic diseases, and a bunch of factors can modify the result of this exam, such as gestational age, weight, need for parenteral nutrition (PTN), vitamins deficiency.
143 - IRT/IRT Strategy for Early Cystic Fibrosis Detection: Importance of Newborn's Day of Life and Methodological Performance
Ana Guercio1, Samanta Bassino1, Belen Castro1, Veronica Lobato1, Agustin Vergara1, and Matias Pirri2
1Programa Prov. de Pesquisa Neonatal-Ce.P.E.I.I. Hospital Pediatrico Dr. Humberto J. Notti, Mendoza, Argentina
2Residencia de Bioquimica Clínica. Dpto. de Bioquimica. Hospital Pediatrico Dr. Humberto Notti, Mendoza, Argentina
144-Clinical Review of Fatty Acids β-Oxidation Diseases Through Extended Newborn Screening in South West of Spain (West Andalusia)
Maria Bueno-Delgado, Joaquin Arjona-Arjona, Carmen Delgado-Pecellin, and Antonio Gonzalez Meneses
Universitary Hospital Virgen Del Rocio, Sevilla, Spain
145 - Results of an Expanded Newborn Screening Program in the Health Services of the Mexican Secretariat of National Defense
Luis Felipe Madrigal Mendoza1, Rolando Bonilla Mendez2, Luz Del Alba Herrera Pérez3, Claudia Moreno-Graciano3, Patricia Martinez-Cruz3, Felipe Angel Maldonado Solis3, Mario Arturo Maldonado Solis3, and Carlos Eduardo Arias Vidal3
1Military Health, Secretariat of National Defense of Mexico, Ciudad de Mexico, Mexico
2Women’s Military Hospital, Secretariat of National Defense of Mexico, Ciudad de Mexico, Mexico
3Tamizmas, Tamizaje Plus Sa de Cv, Mérida, Mexico
146 - The Importance of Newborn Screening in the Diagnosis of Congenital Adrenal Hyperplasia (CAH)—The Brasilia experience
Kallianna Gameleira1, Delmir Rodrigues2, Juliana Thomas3, Romina Soledad Heredia Garcia Silva1, Maria Terezinha Cardoso1, Maria Teresa Rosa1, Graziela Antonialli1, Karine Santielle Pereira Malheiros1, Jeane Mazz1, and Vitor de Araújo4
1Unidade de Genética, Hospital de Apoio de Brasília, Secretaria de Estado de Saúde do Df, Brasília, DF, Brazil
2Coordenação de Pediatria, Secretaria de Estado de Saúde do Distrito Federal, Brasília, DF, Brazil
3Coordenação do Programa de Triagem Neonatal do Distrito Federal, Secretaria de Estado de Saúde do Df, Brasília, DF, Brazil
4Laboratório de Triagem Neonatal, Unidade de Genética, Hospital de Apoio de Brasília, Brasília, DF, Brazil
147 - Five Years of Expanded Newborn Screening Program at Brazil’s Capital
Juliana Thomas1, Graziela Antonialli2, Marcone Viegas2, Rodrigo Oliveira2, Lillian Medeiros2, Anna Christina Silvestre2, Maria Teresa Rosa2, Giselle Maria Adjuto2, Maria Teresinha Cardoso2, Bárbara Cátia Silva2, Monique Poubel2, Karine Santielle Pereira Malheiros2, Kallianna Gameleira2, Graziela Paronetto Machado Antonialli2, Romina Soledad Heredia Garcia Silva2, Fernanda Canuto3, and Miriam Santos3
1Coordenação do Programa de Triagem Neonatal, Secretaria de Estado de Saúde do Distrito Federal, Brasília, DF, Brazil
2Unidade de Genética, Hospital de Apoio, Secretaria de Estado de Saúde do Distrito Federal, Brasília, DF, Brazil
3Saúde da Criança, Secretaria de Estado de Saúde do Distrito Federal, Brasília, DF, Brazil
Brazil has a newborn screening program since 2001. This federal program is funded by the government, and therefore the entire Brazilian population has access to exams for phenylketonuria, congenital hypothyroidism, sickle cell disease, cystic fibrosis, congenital adrenal hyperplasia, and biotinidase deficiency. The Federal District (the country’s capital) has its own newborn screening program, which is funded by local resources without charges for the directly benefited population. This program expanded the disease’s panel to 30 since 2012, including also galactosemia, congenital toxoplasmosis, G6PD deficiency, and 21 inborn errors of metabolism. The Federal District is the only State in South America that provides such service for the population. The aim of this study is to share this experience of an extended newborn screening program in a development country. In the last 5 years were collected samples of 223 836 newborns. The procedure recommended is heel prick which is done prior to discharge in local hospitals or birthing centers so it’s possible to ensure the screen to all newborns. The Federal District’s primary care units can also collect the sample if it is necessary. The samples have been sent to the laboratory in two or three days. From samples to results, the process takes more seven days and the first visit to the specialist occurs in average at the twentieth day of life. In the last five years were screened 8 phenylketonurias, 83 congenital hypothyroidism, 129 SS sickle cell disease, 8 SC sickle cell disease, 13 cystic fibrosis, 12 congenital adrenal hyperplasia, 17 biotinidase deficiency, 14 classic galactosemia, 93 congenital toxoplasmosis, and 86 inborn errors of metabolism. G6PD deficiency is in 4% of the population. The Federal District’s health-care services also provide the appropriate treatment for each disease which ensures the best possible outcome for the babies. The significant number of children treated in an early stage of their diseases justifies the Federal District government investments, what should be expanded to the whole country.
148 - Implementation of Newborn Screening Tests According With Institutional Needs in Mexico
Alejandro Sauza-Taboada, Veronica Mendoza-Vasques, and Estefania Portilla-Mendoza
Ensayos Y Tamizajes de México, S.A. de C.V., Mexico, Mexico
In Mexico, there are approximately 2.2 million births per year, 1.7 million of these births are served in public health care, and the rest in private health care. The health-care institutions offer different newborn screening programs, which are adapted to the economic and incidence needs of each institution. In most of these institutions the most recurrent tests are, 17OH-progesterone, TSH, PKU, galactose, biotinidase, and recently IRT. Ensure that newborn screening tests meet the specific needs of each health-care institutions, to fit their disease prevention programs. Institutional diversity in Mexico requires that newborn screening services be tailored to the needs of each institution. In the public sector, where the majority of births occur, there are specific newborn screening programs that cover the whole country; however, in the private health care, the test profiles are very varied. Our company has efficiently implemented newborn screening tests in various institutions at all country, in the public and private health-care services, which responds to the diverse needs of neonatal screening programs.
149 - Expanded Newborn Screening Program in the Health Services of the Mexican Navy: A 5 Year Experience
Oliver de La Torre García1, Silvia Loo-Salome2, Jorge Valencia-Moncada2, Luis Bonilla-Arcuate2, Roberto Mar-Aldana1, Ramon Salgado-Sangri1, Luz Del Alba Herrera Pérez3, Claudia Moreno-Graciano3, Patricia Martinez-Cruz3, Felipe Angel Maldonado Solis3, Mario Arturo Maldonado Solis3, and Carlos Eduardo Arias Vidal3
1Naval General Hospital of High Specialty, Ciudad de México, Mexico
2Naval Health Services, Ministry of Mexican Navy, Ciudad de México, Mexico
3Tamizmas, Tamizaje Plus S.A. de C.V., Mérida, Mexico
150 - Newborn Screening Program on the Social Security Health Insurance of Peru: Period 2008-2016
Martha Lavado-Ariza, Milagros Dueñas-Roque, Mercedes Arteaga-Cano, Olga Valdivia-Torres, Guadalupe Yi-Zapata, Maybee Azabache-Palomino, Ana Prötzel-Pinedo, and Marco Morales-Acosta
Hospital Nacional Edgardo Rebagliati Martins, Lima, Peru
The universal newborn screening (NBS) program in Peru was created by law N°29885 in June 2012, with congenital hypothyroidism (CH), congenital adrenal hyperplasia (CAH), phenylketonuria (PKU), cystic fibrosis (CF), hearing loss, and congenital cataract as the condition included. Currently, the NBS program at the public sector is in phase of implementation. The Social Security Health Insurance of Peru (EsSalud) attends approximately one-third of total population of the country. Experience in NBS program in EsSalud began in October 2002 for CH and CAH began at Hospital Edgardo Rebagliati Martins of Lima, spreading nationwide since January 2008. In the same year, the screening for PKU and GAL began only at Edgardo Rebagliati Hospital and his affiliated medical centers, spreading nationwide since September 2011.
151 - Experience in Newborn Screening in the Maternity Clinic Rafael Calvo Cartagena. Colombia During the Years 2005-2016
Alicia Gaviria
Ese Clínica de Maternidad Rafael Calvo, Cartagena, Colombia
D) Dietetics and Nutrition (152 to 207)
152 - The Effects of Low Protein Products Availability on Growth Parameters and Metabolic Control in Selected Amino Acid Metabolism Disorders Patients
Bedour Handoom
King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
In Saudi Arabia, a diet for life policy has been adopted in the management of amino acid metabolism disorders for years. However, low protein products—which are one of the important treatment tools—were not available up until several years ago. Our aim was to measure the compliance and quality of life in patients affected with these disorders following in the metabolic nutrition clinic at King Faisal Specialist Hospital & Research Centre (KFSH&RC), Riyadh, Saudi Arabia.
153 - Parent Perceptions of Liberalizing Fat Intake in Children With Very Long-Chain Acyl-CoA Dehydrogenase Deficiency
Antonia Trollip, Bridget Wilcken, and Carolyn Ellaway
Sydney Children’s Hospital Network, Sydney, Australia
154 - The Effect of Ketogenic Diet on Hematological Parameters of Patients With Intractable Epilepsy
Engin Kose1, Orkide Guzel2, and Nur Arslan1
1Dokuz Eylul University, Division of Pediatric Metabolism and Nutrition, Izmir, Turkey
2Mediterranean Type Ketogenic Diet Center, Izmir, Turkey
155 - Propionic Acidemia and Twin Pregnancy: A Case Study
Melanie Hill1, Godfrey Gillett1, Beata Kiec-Wilk2
1Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
2Jagiellonian University Medical College, Krakow, Poland
156 - Do Amino Acid Medical Foods Negatively Impact Skeletal Health in Phenylketonuria?
Bridget Stroup1, Emily Sawin1, Sangita Murali1, Neil Binkley2, Karen Hansen2, and Denise Ney1
1University of Wisconsin–Madison, Madison, WI, USA
2University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
157 - In Methylmalonic Acidemia and Propionic Acidemia Does the Removal of Precursor Free Amino Acid Supplementation Affect Long-Term Metabolic Stability, Plasma Amino Acid Status and Growth?
Anne Daly, Satnam Chahal, Sharon Evans, Alex Pinto, and Anita Macdonald
Birmingham Women’s and Children’s Hospital, Birmingham, United Kingdom
158 - Dietary Management of Galactosemia With Galactose Restricted Diet
Umair Mahmood1, Huma Arshad Cheema2, Saqib Mahmood3, Pervez Akhtar1, and Shahid Ur Rehman Mahmood1
1University of Agriculture Faisalabad Sub Campus Toba Tek Singh, Toba Tek Singh, Pakistan
2The Children’s Hospital and Institute of Child Health, Lahore, Pakistan
3University of Health Sciences, Lahore, Pakistan
Type I galactosemia is an inborn error resulting from mutations on both alleles of the GALT gene which leads to absence or deficiency of galactose-1-phosphate uridyltransferase (GALT). Galactose-1-phosphate accumulates within cells, and surplus galactose is reduced to galactitol or oxidized to galactonate. It is characterized in its early stages by hepatocellular damage (jaundice, hepatomegaly, and abnormal liver function tests), food intolerance (vomiting, diarrhea, and poor feeding) and failure to thrive. Patients with this condition have substantial motor, cognitive, and psychiatric impairments despite dietary treatment. Classical galactosemia is frequently associated with Q188 R, S135 L, and K285 N mutations and N314D is associated with Duarte galactosemia and is wide spread among various worldwide populations. The objectives of this study are to evaluate the presence of urinary galactitol to monitor the soy formula diet of patients with galactosemia. The present study aims to detect urinary galactitol by quantitative Benedict’s test with galactose restricted diet based on soy formula. Unexpectedly, galactitol was found in the urine of all patients receiving a galactose-restricted diet (soy formula), and postulated that this sugar alcohol has its origin in part from endogenously produced galactose. There are still dilemmas about the management of galactosemia with galactose restricted diet and patients suffer from psychomotor abnormalities with hypogonadism in women irrespective of dietary management.
159 - Metabolomic Insights Into Lipid Metabolism in Phenylketonuria: Essential Fatty Acids, Cholesterol, Carnitine, and Choline
Bridget Stroup1, Nivedita Nair1, Sangita Murali1, Kataryzna Broniowska2, and Denise Ney1
1University of Wisconsin–Madison, Madison, WI, USA
2Metabolon, Inc., Morrisville, NC, USA
160 - Dietetic Management of Infants Screened Positive for Glutaric Aciduria Type 1 (GA1) on Expanded Newborn Screening (ENBS)—A single Centre’s Experience
Sarah Cawtherley, Rachel Skeath, James Davison, Maureen Cleary, Emma Footitt, Paul Gissen, Stephanie Grunewald, and Marjorie Dixon
Great Ormond Street Hospital, London, United Kingdom
161 - Is Diagnosing Patients With Organic Acidurias and Aminoacidopathies Enough? Conundrums of a Low Middle Income Country
Hafsa Majid1, Aysha Habib Khan1, Lena Jafri1, Zeba Zulfiqarali1, and Bushra Afroze2
1Aga Khan University Hospital, Karachi, Pakistan
2Aga Khan University Hospital, Karachi, Pakistan
162 - Glycogen Storage Disease Type Ib. Nutritional Outcome Post Liver Transplant
Steve Kitchen, Anne Daly, and Anita Macdonald
Birmingham Women’s and Children’s Hospital, Birmingham, United Kingdom
163 - Maternal Depression and Anxiety of Patients Under Restricted Diet and Having Risk of Metabolic Decompensation
Pelin Teke Kisa1, Engin Kose1, Ozlem Unal2, Selda Bülbül3, Mehmet Gunduz2, and Nur Arslan1
1Division of Pediatric Metabolism and Nutrition, Dokuz Eylul University Faculty of Medicine, İzmir, Turkey
2Division of Pediatric Metabolism and Nutrition, Ankara Children’s Education and Research Hospital, Ankara, Turkey
3Division of Pediatric Metabolism and Nutrition, Kirikkale University, Kirikkale, Turkey
164 - The Effect of Home Visiting to the Ketogenic Diet Compliance in Multi-Drug Resistant Epilepsy
Nevra Koç, Mehmet Gündüz, Özlem Ünal, Aynur Kucukcongar Yavas, and Aydan Değerliyurt
Children Health and Diseases Hematology Oncology Education and Training Hospital, Ankara, Turkey
165 - Nutritional Status and Protein Energy Ratio in Patients with Phenylketonuria
Sara Guillén López1, Lizbeth Lopez-Mejia1, Merit Valeria Juarez Cruz2, Cynthia Fernandez-Lainez1, Isabel Ibarra González3, Leticia Belmont-Martinez4, and Marcela Vela-Amieva4
1Laboratorio de Errors’ Innatos Del Metabolismo Y Tamiz, Inp, Ss., Ciudad de México, Mexico
2Instituto Politécnico Nacional, Ciudad de México, Mexico
3Unidad de Genética de La Nutrición, Ibid, Unum., Ciudad de México, Mexico
4Laboratorio de Errores Innatos Del Metabolismo Y Tamiz, Inp, Ss, Ciudad de México, Mexico
166 - Does the Additional Phenylalanine in GMP-AA Protein Substitute Lead to Destabilization of Blood Phenylananine Concentrations Compared to Conventional Amino Acid Protein Substitutes?
Anne Daly1, Satnam Chahal1, Sharon Evans2, Alex Pinto1, Cerys Gingell3, Júlio Rocha4, and Anita Macdonald1
1Birmingham Women’s And Children’s Hospital, Birmingham, United Kingdom
2Birmingham Women’s And Children’s Hospital, Birmingham, United Kingdom
3Nottingham University Hospital, Queens Medical Centre, Nottingham, United Kingdom
4Centro Di Genetics Medica, Centro Hospitalar do Porto (Chp) Proto, Porto, Portugal
167 - Low Protein Mobile and Web-Based Diet Applications: What’s Out There?
Sharon Evans, Ozlem Yilmaz, Alex Pinto, Anne Daly, and Anita Macdonald
Birmingham Women’s And Children’s NHS Foundation Trust, Birmingham, United Kingdom
168 - UK BIMDG Dietetic Consensus Guidelines on Low Protein Labeling Interpretation and Food Allocation for Patients and Caregivers With PKU
Sharon Evans1, Suzanne Ford2, and Anita Macdonald1
1Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, United Kingdom
2Nspku, Purley, United Kingdom
169 - Dietary Management of Early Onset Lysosomal Acid Lipase Deficiency (LAL-D/Wolman Disease): A Case Report
Eleana Petropoulou, Rosie Jones, Anne Daly, Catherine Ashmore, Rachel Hoban, Steve Kitchen, Alex Pinto, Suresh Vijayaraghavan, Saikat Santra, and Anita Macdonald
Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, United Kingdom
170 - Growth of Children With Phenylketonuria Taking a Semi-Solid Weaning Protein Substitute is Comparable to Control Children in the First 2 Years of Life
Sharon Evans1, Anne Daly1, Jo Wildgoose2, Barbara Cochrane3, Satnam Chahal1, Catherine Ashmore1, and Anita Macdonald1
1Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, United Kingdom
2Bradford Teaching Hospital, Bradford, United Kingdom
3Royal Hospital for Sick Children, Glasgow, Scotland, United Kingdom
171 - Dietary Management of a Premature Infant With Medium Chain Acyl-CoA Dehydrogenase Deficiency (MCADD)
Eleana Petropoulou, Anne Daly, Catherine Ashmore, Rachel Hoban, Rosie Jones, Steve Kitchen, Rachel Gould, Saikat Santra, Suresh Vijayaraghavan, and Anita Macdonald
Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, United Kingdom
172 - Help! My Home is Making Me Sick
Satnam Chahal, Anne Daly, Catherine Ashmore, Anita Macdonald, Alex Pinto
Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, United Kingdom
173 - 3 Month Audit Data of 24 Hour Dietetic On-Call Service in Inherited Metabolic Disease
Steve Kitchen, Anne Daly, Rachel Hoban, Catherine Ashmore, Eleana Petropoulou, and Anita Macdonald
Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, United Kingdom
174 - International Practices in the Dietary Management of Fructose 1-6 Biphosphatase Deficiency
Alex Pinto1, Anne Daly1, Sharon Evans1, Júlio Rocha2, and Anita Macdonald1; *On behalf of SSIEM members who contributed to this project
1Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, United Kingdom
2Centro de Genética Médica, Centro Hospitalar do Porto (Chp), Porto, Portugal
175 - Dietary Management of Maternal Phenylketonuria With Glycomacropeptide: A Case Report
Alex Pinto1, Manuela Almeida2, Ana Cunha3, Carla Carmona2, Sara Rocha3, Arlindo Guimas3, Rosa Ribeiro3, Ceu Mota4, Esmeralda Martins3, Anita Macdonald1, and Júlio Rocha2
1Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, United Kingdom
2Centro de Genética Médica, Centro Hospitalar do Porto (Chp), Porto, Portugal
3Unidade de Doenças Metabólicas, Centro Hospitalar do Porto, Chp, Porto, Portugal
4Serviço de Cuidados Intensivos, Unidade de Neonatologia, Cmin, Centro Hospitalar do Porto, Chp, Porto, Portugal
176 - Dietary Management in Pyridoxine-Dependent Epilepsy (PDE) due to Antiquitin Deficiency: A Single Center Experience
Victoria Hunn1, Emma Footitt2, and Marjorie Dixon1
1Dietetics, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
2Metabolic Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
177 - Ensuring Optimal Nutritional Management for Adult Inpatients With Inborn Errors of Metabolism
Clare Kreis1, Jim Mcgill1, and Barbara Van Der Meij2
1Queensland Lifespan Metabolic Medicine Services, Mater Group, Brisbane, Australia
2Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
178 - Retrospective Audit of the Dietary Management of Current Patients with Glutaric Aciduria Type 1 at a Single Metabolic Center
Tess Stanway1, Ashleigh Mitchell1, Carolyn Ellaway2, Kaustuv Bhattacharya2, and Susan Thompson2
1Nutrition and Dietetics, The Children’s Hospital at Westmead, Sydney, Australia
2Genetic Metabolic Disorders Service, The Children’s Hospital at Westmead, Sydney, Australia
Glutaric Aciduria type 1 (GA1) (glutaryl-CoA dehydrogenase deficiency) affects the catabolism of L-lysine, L-hydroxylysine and L-tryptophan. Untreated individuals typically experience acute encephalopathic crisis during the first 6 years of life. In line with SSIEM guidelines, dietary management of GA1 at the Genetic Metabolic Disorders Service (GMDS) Sydney includes regular review, aggressive emergency treatment, and a lysine restricted diet supplemented with lysine-free, tryptophan-reduced amino acid mixture (AAM) and L-carnitine. Emergency and diet plans are individualized. Protein counting or limiting high protein food, is used as a simpler way to reduce lysine, based on plasma lysine levels.
179 - Feeding Outcomes Pre and Post Liver Transplant in Pediatric Patients with Urea Cycle Disorders and Organic Acidemias
Carla Fitzachary1, Roshni Vara2, Mike Champion2, Helen Mundy2, Hugh Lemonde2, and Joanna Gribben1
1Nutrition & Dietetic Dept, Guy’s & St Thomas’ NHS Foundation Trust, London, United Kingdom
2Centre For Inherited Metabolic Disease, Evelina London, Guy’s & St Thomas’ NHS Foundation Trust, London, United Kingdom
180 - Follow-Up of the Nutritional Treatment of a Patient With Biochemical and Molecular Diagnosis of 3 MCC: Case Report
Maria Alejandra Sanchez1, Graciela Arelí López Uriarte2, María Del Rosario Torres Sepúlveda2, Karla Alejandra Serrato Sánchez2, Adrián Martínez Cervantes3, and Laura Elia Martínez Garza2
1Universidad Autónoma de Nuevo Leon, Monterrey Nuevo León, Mexico
2Universidad Autónoma de Nuevo León, Monterrey Nuevo León, Mexico
3Universidad de Monterrey, Monterrey Nuevo León, Mexico
181 - Innovative Model for Delivering Online Genetic Metabolic Nutrition Education: A Pilot Project (Phase I)
Rosalynn Blair1, Teresa Douglas1, Theresa Pringle1, Adrya Stembridge1, Leah Chuchran-Davis2, and Rani Singh1
1Emory University, Atlanta, GA, USA
2Consultant, Asheville, TX, USA
182 - Improvement of Nutritional Intake for a Complex MMA Patient Following Implementation of Australia’s First Hospital Room Service Choice on Demand: A Case Study
Clare Kreis1, Jim Mcgill1, Barbara Van Der Meij2, and Sally Mccray3
1Queensland Lifespan Metabolic Medicine Services, Mater Group, Brisbane, Australia
2Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
3Department of Nutrition and Dietetics, Mater Group, Brisbane, Australia
183 - Challenges of Initiating Low Protein Diets in Toddlers: A Patient With Arginase Deficiency
Erin Mullane, Jamie Errico, and Maureen Evans
Royal Children’s Hospital, Melbourne, Australia
184 - A Severe Hypertriglyceridemia in Berardinelli-Seip Congenital Lipodystrophy—Nutritional Management
Ana Vieira and Helena Santos
Chvng, Vila Nova de Gaia, Portugal
185 - Energy and Nutrient Intakes in PKU Patients in Relative to the Turkey Dietary Guidelines
Ozlem Yilmaz1, Berrak Bilginer Gürbüz2, Yilmaz Yildiz2, Emine Goksoy2, Ali Dursun2, Serap Sivri2, Ayşegül Tokatli2, Turgay Coskun2, and Hülya Gökmen Özel1
1Hacettepe University, Faculty of Health Sciences, Department of Nutrition and Dietetics, Ankara, Turkey
2Metabolism Unit, Department of Paediatrics, Hacettepe University School of Medicine, Ankara, Turkey
186 - The Contribution of Food Groups to the Daily Energy, Protein, and Phenylalanine Intakes in Patients With PKU
Ozlem Yilmaz1, Berrak Bilginer Gürbüz2, Yilmaz Yildiz2, Emine Goksoy2, Ali Dursun2, Serap Sivri2, Ayşegül Tokatli2, Turgay Coskun2, and Hülya Gökmen Özel1
1Hacettepe University, Faculty of Health Sciences, Department of Nutrition and Dietetics, Ankara, Turkey
2 Metabolism Unit, Department of Paediatrics, Hacettepe University School of Medicine, Ankara, Turkey
187 - Production of Enteral Feeds for Inpatients With Inborn Errors of Metabolism in a Pediatric Hospital
Araceli Cresta, Silvana Lavorgna, Laura Giusti, and Sandra Blasi
Hospital de Pediatría J.P.Garrahan, Buenos Aires, Argentina
Garrahan Hospital is a public referral center (534 total beds) for complex pediatric diseases, including inborn errors of metabolism (IEM) that require a special individualized diet. Around 1400 enteral feeds for inpatients are prepared every day by trained personnel in a Formula Room under the supervision of specialized dietitians. The aim of this study was to describe the production of enteral feeds for inpatients with IEM during the last year in our center.
188 - Micronutrient Status in Patients With Phenylketonuria: The Role of Protein Substitutes Intake
Paula Cristina Ramos1, Júlio Rocha2, Esmeralda Martins3, Rosa Ribeiro4, Anabela Bandeira4, Arlindo Guimas4, Sara Rocha4, and Manuela Almeida5
1Fac Med Univ Porto (Fmup)., Cent Gen Med, Chp, Porto, Portugal
2Cent Gen Med, Chp, Cent Ref Dhm, Chp, Cent Health Tech Serv And Res (Cintesis), Fac Health Sci, Ufp., Porto, Portugal
3Cent Ref Dhm, Chp, Umib/Icbas/Up., Porto, Portugal
4Cent Ref Dhm, Chp., Porto, Portugal
5Cent Gen Med, Chp, Cent Ref Dhm, Chp, Umib/Icbas/Up., Porto, Portugal
189 - Home Visit Program in Patients with PKU: Does It Affect Blood Phenylalanine Levels?
Hülya Gökmen Özel1, Ozlem Yilmaz1, Berrak Bilginer Gürbüz2, Yilmaz Yildiz2, Emine Goksoy2, Ali Dursun2, Serap Sivri2, Ayşegül Tokatli2, and Turgay Coskun2
1Faculty of Health Sciences, Department of Nutrition and Dietetics, Hacettepe University, Ankara, Turkey
2Metabolism Unit, Department of Paediatrics, Hacettepe University School of Medicine, Ankara, Turkey
190 - Phenylalanine and Protein Intakes in Patients With PKU: Do They Adhere to Dietary Recommendations?
Ozlem Yilmaz1, Berrak Bilginer Gürbüz2, Yilmaz Yildiz2, Emine Goksoy2, Ali Dursun2, Serap Sivri2, Ayşegül Tokatli2, Turgay Coskun2, and Hülya Gökmen Özel1
1Faculty of Health Sciences, Department of Nutrition and Dietetics, Hacettepe University, Ankara, Turkey
2Metabolism Unit, Department of Paediatrics, Hacettepe University School of Medicine, Ankara, Turkey
191 - Do Dietary Energy and Protein Intakes Affect on Anthropometric Measurements in PKU Children?
Ozlem Yilmaz1, Berrak Bilginer Gürbüz2, Yilmaz Yildiz2, Emine Goksoy2, Ali Dursun2, Serap Sivri2, Ayşegül Tokatli2, Turgay Coskun2, and Hülya Gökmen Özel1
1Hacettepe University, Faculty of Health Sciences, Department of Nutrition and Dietetics, Ankara, Turkey
2Hacettepe University, School of Medicine, Department of Paediatrics, Metabolism Unit, Ankara, Turkey
192 - Phenylalanine Intake from Free Foods in Patients with PKU: Do They Contribute Significant Amount to Daily Phenylalanine Intake?
Hülya Gökmen Özel1, Ozlem Yilmaz1, Berrak Bilginer Gürbüz2, Yilmaz Yildiz2, Emine Goksoy2, Ali Dursun2, Serap Sivri2, Ayşegül Tokatli2, and Turgay Coskun2
1Faculty of Health Sciences, Department of Nutrition and Dietetics, Hacettepe University, Ankara, Turkey
2 Metabolism Unit, Department of Paediatrics, School of Medicine, Hacettepe University, Ankara, Turkey
193 - Types of Protein Substitutes in PKU: Do Patients Still Prefer High Volume, High Energy Drinks?
Hülya Gökmen Özel1, Ozlem Yilmaz1, Berrak Bilginer Gürbüz2, Yilmaz Yildiz2, Emine Goksoy2, Ali Dursun2, Serap Sivri2, Ayşegül Tokatli2, and Turgay Coskun2
1Faculty of Health Sciences, Department of Nutrition and Dietetics, Hacettepe University, Ankara, Turkey
2Metabolism Unit, Department of Paediatrics, Hacettepe University School of Medicine, Ankara, Turkey
194 - Overweight and Obesity Prevalence in Children With Medium-Chain acyl-CoA Dehydrogenase Deficiency From a single UK Centre Compared to the UK Population
Arlene Slabbert1, Mike Champion2, Hugh Lemonde2, Helen Mundy2, Roshni Vara2, and Joanna Gribben1
1Nutrition & Dietetic Department, Guy’s & St Thomas’ NHS Foundation Trust, London, United Kingdom
2Centre For Inherited Metabolic Disease, Evelina London, Guy’s & St Thomas’ NHS Foundation Trust, London, United Kingdom
195 - Dietary Compliance During BH4 Loading Test in Patients With Phenylketonuria
Beatriz Mina1, Manuela Almeida2, Sara Rocha3, Arlindo Guimas3, Rosa Ribeiro3, Esmeralda Martins3, Anabela Bandeira3, Rui Meireles Barros4, Anita Macdonald5, and Júlio César Rocha6
1Cent Gen Med, Chp, Esc Sup Biotec, Univ Catol Port., Porto, Portugal
2Cent Gen Med, Chp, Cent Ref Dhm, Chp, Umib/Icbas/Up., Porto, Portugal
3Cent Ref Dhm, Chp., Porto, Portugal
4Esc Sup Biotec, Univ Catol Port., Porto, Portugal
5The Children’s Hospital., Birmingham, United Kingdom
6 Fac Health Sci, Cent Gen Med, Chp, Cent Ref Dhm, Chp, Cent Health Tech Serv And Res (Cintesis), Ufp., Porto, Portugal
196 - Metabolic Control in Patients With Phenylketonuria (PKU): Impact of Phenylalanine Titration for BH4 Loading Test
Catarina Sousa Barbosa1, Manuela Almeida2, Cátia Sousa1, Sara Rocha3, Arlindo Guimas3, Rosa Ribeiro3, Esmeralda Martins3, Anabela Bandeira3, Bruno Miguel Paz Mendes Oliveira4, Nuno Borges5, Anita Macdonald6, and Júlio César Rocha7
1Fac Cienc Nutr Alim Univ Porto., Cent Gen Med, Chp, Porto, Portugal
2Cent Gen Med, Chp, Cent Ref Dhm, Chp, Umib/Icbas/Up., Porto, Portugal
3Cent Ref Dhm, Chp., Porto, Portugal
4Fac Cienc Nutr Alim Univ Porto., Porto, Portugal
5Fac Cienc Nutr Alim Univ Porto, Cent Health Tech Serv And Res (Cintesis)., Porto, Portugal
6The Children’s Hospital., Birmingham, United Kingdom
7 Fac Health Sci, Cent Gen Med, Chp, Cent Ref Dhm, Chp, Cent Health Tech Serv And Res (Cintesis), Ufp., Porto, Portugal
197 - Ketogenic Diet in Children With Drug-Resistant Epilepsy, GLUT-1 Deficiency syndrome and Pyruvate Dehydrogenase Complex Deficiency
Miraç Yildirim, Ceren Günbey, Fatma Ilgaz, Dilek Yalnizoğlu, Meral Topcu
Hacettepe University, Ankara, Turkey
198 - The European Phenylketonuria (PKU) Guidelines and the Challenges on Management Practices in Portugal
Cátia Sousa1, Manuela Almeida2, Catarina Sousa Barbosa1, Esmeralda Martins3, Patricia Janeiro4, Isabel Tavares de Almeida5, Anita Macdonald6, and Júlio César Rocha7
1Fac Cienc Nutr Alim Univ Porto., Cent Gen Med, Chp, Porto, Portugal
2Cent Gen Med, Chp, Cent Ref Dhm, Chp, Umib/Icbas/Up., Porto, Portugal
3Cent Ref Dhm, Chp, Umib/Icbas/Up., Porto, Portugal
4Cent Ref Dhm, Chln, Hospital de Sta. Maria., Lisboa, Portugal
5Metab Genet Gr, Fac Pharm Univ Lisb., Lisboa, Portugal
6The Children’s Hospital., Birmingham, United Kingdom
7Fac Health Sci, Cent Gen Med, Chp, Cent Ref Dhm, Chp, Cent Health Tech Serv And Res (Cintesis), Ufp., Porto, Portugal
199 - The Incidence of Overweight and Obesity in Irish Children With Phenylketonuria (PKU) Compared With the Growing Up in Ireland Study
Aoife Fitzgerald1, Emilie Serve2, Ardeshir Monavari1, Joanne Hughes1, Jenny Mcnulty1
1National Centre For Inherited Metabolic Disorders, Temple Street Children’s University Hospital, Dublin, Ireland
2Clermont-Ferrand Hospital: Chu Clermont, Inserm Cic-1405, Pediatrie, Chu Estaing 1 Place Lucie Aubr, Clermont, France
200 - Nutritional Status in BH4 Treated Patients With Phenylketonuria: Preliminary Data From TNSPKU Project
Júlio César Rocha1, Manuela Almeida2, Sara Rocha3, Arlindo Guimas3, Rosa Ribeiro3, Esmeralda Martins4, Anabela Bandeira3, Nuno Borges5, Anita Macdonald6, and Van Spronsen Francjan7
1 Fac Health Sci, Cent Gen Med, Chp, Cent Ref Dhm, Chp, Cent Health Tech Serv And Res (Cintesis), Ufp., Porto, Portugal
2Cent Gen Med, Chp, Cent Ref Dhm, Chp, Umib/Icbas/Up., Porto, Portugal
3Cent Ref Dhm, Chp., Porto, Portugal
4Cent Ref Dhm, Chp, Umib/Icbas/Up., Porto, Portugal
5Fac Cienc Nutr Alim Univ Porto, Cent Health Tech Serv And Res (Cintesis)., Porto, Portugal
6The Children’s Hospital., Birmingham, United Kingdom
7Beatr Child Hosp, Univ Med Cent., Groningen, the Netherlands
201 - Intravenous Sources of Medium Chain Triglycerides for Critically Ill Patients With Fatty Acid Oxidation Disorders
Heather Bausell1, Katherine Kim1, and Barbara Burton2
1Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
2Northwestern University Feinberg School of Medicine, Chicago, IL, USA
202 - Growth Evaluation and Biochemical Profile of Patients With Glycogen Storage Disease Type I Under Treatment With Uncooked Corn Starch Therapy: Retrospective Study
Renata Oliveira, Bernardes, Beatriz J., Frangipani, José Silva, Oliveira Araújo, Ana Paula Pessoa, Ferreira, Sandra Obikawa Kyosen, and Ana Maria Martins
Unifesp, São Paulo, SP, Brazil
203 - Body Composition in Patients with Urea Cycle Disorders on Protein Restricted Diet
Cristina Bonfanti1, Serena Gasperini2, Cinzia Galimberti2, Miriam Rigoldi3, Serena Tursi2, Roberta Pretese2, Maria Luisa Bianchi4, Fabio Scotti5, and Rossella Parini2
1Faculty of Sciences and Technology, Milano University, Milano, Italy
2Metabolic Unit, Mbbm Foundation, S. Gerardo Hospital, Milano-Bicocca University, Monza, Italy
3Rare Diseases Unit, Internal Medicine Department, San Gerardo Hospital, Monza, Italy
4Bone Metabolism Unit, Istituto Auxologico Italiano Irccs, Milano, Italy
5Department of Computer Science, Milano University, Milano, Italy
204 - Acute Effect of a Phenylalanine-Free Amino Acid Mixture on the Glycidic Metabolism in the Rat
Maria João Pena1, Susana Gomes Guerreiro2, Júlio César Rocha3, Tiago Morais4, Sofia Silva Pereira5, Mariana Monteiro4, and Nuno Borges6
1Dep Biomed Unid Bioq Fmup, Inst Inv Inov Saude (I3 s), Cent Gen Med, Chp, Cent Ref Dhm, Chp Up., Porto, Portugal
2Dep Biomed Unid Bioq Fmup, Inst Inv Inov Saude (I3 s), Up, Ciênc Quim Biomol, Cisa, Estsp, Ipp., Porto, Portugal
3Fac Health Sci, Cent Gen Med, Chp, Cent Ref Dhm, Chp, Cent Health Tech Serv And Res (Cintesis), Ufp., Porto, Portugal
4Clinical and Experimental Endocrinology, Umib/Icbas/Up., Porto, Portugal
5Inst Mol Path Immu Up (Ipatimup).,Clinical and Experimental Endocrinology, Umib/Icbas/Up, Porto, Portugal
6Fac Cienc Nutr Alim Univ Porto, Cent Health Tech Serv And Res (Cintesis)., Porto, Portugal
205 - Dietary Treatment in Patients with HIBCH and ECHS1 Defects: Clinical and Biochemical Response to Low-Valine Diet
Jose Abdenur1, Mariella Simon1, Mary Sowa1, Janette Skaar1, Richard Chang1, Maija Steenari2, and James Pitt3
1Choc Children’s, Division of Metabolic Disorders, Orange, CA, USA
2Choc Children’s, Division of Pediatric Neurology, Orange, CA, USA
3Victorian Clinical Genetics, Murdoch Research Institute, Melbourne, Australia
206 - Clinical characterization, metabolic and nutritional profile of patients with Maple Syrup Urine Disease accompanied at a Center of Reference in Inborn Errors of Metabolism
Beatriz J. Frangipani, Renata Oliveira, Bernardes, José Silva, Oliveira Araújo, Rachel Ricci, Sandra Obikawa Kyosen, Marco Curiati, and Ana Maria Martins
Unifesp, São Paulo, SP, Brazil
207 - Influence of a Phe-Restricted Diet on Growth Development From Birth to Age 18 Years in Patients With PKU: A Multicenter European Study
S Stanescu1, K Dokoupil2, P Rzehak2, A Belanger-Quintana1, K Ahring3, H Gokmen Ozel4, A MacDonald5, M Robert6, Almeida MF7,8, JC Rocha7,9,10, M van Rijn11
1U. Enf. Metabolicas, Hosp Ramon y Cajal, Madrid, Spain
2Dr. von Hauner Children's Hospital, Ludwig-Maximilians Universität München (LMU), Munich, Germany
3Center for PKU, Kennedy Institute, Glostrup, Denmark
4Dp Nutrition Dietetics, Hacettepe Univ, Ankara, Turkey
5Dietetic Dept, Children's Hospital, Birmingham, United Kingdom
6Dp Nutr Metab, Hosp Uv Enf Reine Fabiola, Brussels, Belgium
7Centro de Genética Médica, Centro Hospitalar do Porto (CHP), Porto, Portugal
8Unit for Multidisciplinary Research in Biomedicine, Abel Salazar Institute of Biomedical Sciences, University of Porto-UMIB/ICBAS/UP, Porto, Portugal
9Faculdade de Ciências da Saúde, Universidade Fernando Pessoa, Portugal
10Centre for Health Technology and Services Research (CINTESIS), Portugal
11S. Metab Dis, Univ Med Centre Groningen, Groningen, Netherlands
E) New Metabolic Disease Groups (208 to 218)
208 - SOPH Syndrome Causes Recurrent Acute Liver Failure With Onset in Infancy
Qian Yao, Wei Wu, and Xiaoping Luo
Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
SOPH syndrome (MIM 614800) is a clinically rare disease characterized by severe postnatal growth retardation, aging, cutis laxa, osteoporosis, optic atrophy, neutrophil karyotype abnormality, and normal intelligence. It is a disease caused by biallelic mutations in the neuroblastoma amplified sequence (NBAS) gene and inherited by an autosomal recessive fashion. Here we report a girl had SOPH syndrome with RALF starting in infancy. Our patient was a 1.5 years old girl with recurrent acute liver dysfunction, complicated with febrile infections. After our physical examination, head circumference 42.5 cm, unclosed bone joints, anterior fontanel 5*7 cm, wide and uplift forehead, protruding deep eyes, low ear, small jaw, and short limbs were observed. Blood routine showed blood cell count was normal, but blood smears showed the Pelger-Huët anomaly of granulocytes. Liver function showed elevated ALT (up to 663U/L) and AST (up to 218U/L). After several days of parenteral application of lipids and glucose infusion, her ALT and AST was decreased to 189 U/L and 140 U/L, respectively. Her birth weight and length were 1650 g (<3rd centile) and 40 cm (<3 rd centile), respectively. She presented at 1 month of life with fever, cough, and elevated alanine (up to 95U/L) and aspartate transaminases (up to 200U/L), after treated with antibiotic and hepatic protective drugs in several days, both ALT and AST didn’t decrease significantly. She presented several similar episodes in the first 6 months of life, always triggered by fever. At the age of 7 months, she was diagnosed with SOPH syndrome according to gene detection (two heterozygous mutations were found in the NBAS gene: C.6496_6497insA, p.S2166Ffs*2 (maternal), unreported yet; c.5741C> T, p.R1914H(paternal), known mutations). Acute liver failure (ALF) in infancy and childhood is a life-threatening emergency and in about 50% the etiology remains unknown. It is reported that biallelic mutations in NBAS were confirmed as a new molecular cause of RALF with onset in infancy. So, in our clinical works, genetic diagnosis plays an indispensable role in patients with etiology unclear RALF.
209 - Aminoacylase 1 Deficiency in an Infant With Congenital Anomalies and a Spinal Tumor
Premala Muthukumarasamy, Meow Keong Thong, Pavai Sthaneswar, Lucy Lum Chai See, Chin Seng Gan, and Tsiao Yi Yap
University Malaya Medical Centre, Kuala Lumpur, Malaysia
Aminoacylase 1 (ACY1) deficiency (OMIM # 609924) is a rare autosomal recessive disorder characterized by nonspecific psychomotor delay, neurodevelopmental regression, seizures, or normal clinical features. There have been 9 reported cases to date (Engelke 2008). It is largely heterogeneous in clinical presentation and only recently have been described as an inborn error of metabolism (Sass et al 2006). Aminoacylase 1 is a zinc binding enzyme encoded by the ACY1 gene, found on the short arm of chromosome 3. It hydrolyzes N-acetyl amino acids into free amino acid and acetic acid; the deficiency of which leads to accumulation of N-acetyl amino acids in the urine. Most mutations of the ACY1 gene result in complete loss of enzyme activity (Sommer et al 2011). We report a patient with atypical features of ACY1 deficiency, diagnosed by urinary excretion of large amounts of N acetylated amino acids and confirmed by genetic mutation analysis. She was born from parents of a consanguineous marriage, with central hypotonia, hypertelorism, bilateral cleft lip and palate, multiple muscular ventricular septal defects requiring antifailure medications, and nasogastric tube feeding to achieve adequate nutrition. At age 10 weeks, she presented with neuroregression, right sided limb weakness, and a rapidly progressive right cervical mass. A guided biopsy of the mass showed a malignant primitive neuroectodermal (PNET) tumor. She developed worsening neurologic and respiratory compromise and died at the age of 14 weeks. Molecular genetic analysis demonstrated a missense homozygous mutation c.827 G > A (p.Arg276His) of the ACY1 gene. Parental genetic testing is pending. Parental urinary organic acid analyses showed her father to be an excretor of N-acetyl amino acids. He was otherwise asymptomatic with no history of cognitive, neurological, or muscular impairments. It is still unclear if ACY1 deficiency is a metabolic disorder caused by an enzyme deficiency culminating in a heterogeneous clinical phenotype or simply a biochemical abnormality. In 2006, Sass et al reported 4 individuals of variable presentation with ACY 1 mutations, functional ACY1 deficiency, and excretion of N acetylated amino acids and argued that ACY1 deficiency may be a modifying factor later in life. Observation of individuals with ACY1 deficiency along with family studies is important in order to reduce erroneous diagnosis, improve management, and prognostication.
210 - Understanding the Functional Impact of Movement Disorders in Glucose Transporter Type 1 Deficiency Syndrome (Glut1 DS)
Alexandra Bowden1, Peter Collins1, Susan Blair1, Kimberly Wesdock1, Madelyn Haller1, Melanie Brandabur1, Rebecca Hall2, Sarah Kilgariff2, Rob Arbuckle2, and Jill Mayhew1
1Ultragenyx Pharmaceutical, Inc., Novato, CA, USA
2Adelphi Values, Bollington, United Kingdom
Glut1 DS is a rare, genetic, metabolic disorder characterized by impaired glucose transport across the blood–brain barrier, leading to a state of cerebral energy deficiency. Glut1 DS symptoms include seizures, developmental delay, paroxysmal movement disorders, and nonmotor manifestations. Limited information detailing the burden of Glut1 DS movement disorders exists. This study was conducted to explore the patient experience of Glut1 DS movement disorders and their functional impacts. A 1-day study visit (n = 7) and telephone interviews (n = 10) were conducted with Glut1 DS patients and caregivers. This included semistructured clinical interviews about symptoms and impacts, questionnaires (SF-10/SF-12v2), tests of walking capacity (12 Minute Walk Test (12MWT)) and fine/gross motor function (BOT-2), and clinician-rated scales of ataxia and abnormal involuntary movements. Actigraphy was assessed for ≤10 days after the study visit. Videos of movement disorders were submitted for review and comment by 2 expert clinicians. Ataxia, dysarthria, dystonia, and chorea/myoclonus were the most frequently reported movement disorders. Ataxia and dysarthria were primarily described as persistent manifestations, whereas dystonia and myoclonus/chorea were typically paroxysmal. Movement disorders were reported to affect walking, balance, coordination, exercise, and activities of daily living (ADLs) as well as social, emotional, and psychological impacts. Mean SF-10 Physical Summary Scores reflected impaired physical health secondary to movement disorders with scores ∼3SD below normative values. Performance based tests revealed decreased walking capacity, with a mean 6-minute walk distance of 69% predicted during the 12MWT. Fine and gross motor function were not consistently impaired based on BOT-2 scores. Clinician-rated scales showed a minimal level of ataxia and abnormal movements at the time of testing. Of note, no subjects experienced paroxysmal symptoms during assessments. Actigraphy analysis suggested significantly less daytime activity compared to controls. Patients with Glut1 DS experience a wide range of debilitating movement disorders affecting physical function, ADLs, and HRQoL. The variable and often unpredictable nature of paroxysmal movement disorders in Glut1 DS has a significant effect on those living with Glut1 DS. This evidence expands on the limited information on the burden of movement disorders and disabling impacts experienced by patients with Glut1 DS.
211 - Severe Metabolic Abnormalities Observed in Patients with Confirmed Diagnosis of Congenital Generalized Lipodystrophy Including AGPAT2 and BSCL2 Mutations
Renan Montenegro Jr., Virginia Fernanades1, Taylor Salinardi, Phd2, Cristina Heideier2, Ana Montenegro1, Clarisse Ponte1, Izabella Vasconcelos1, Lia Karbage1, Priscila Fernandes1, Annelise Carvalho1, Livia de Araújo Batista1, Luana Lima1, Christiane Liberato1, and Catarina D’Alva1
1Universidade Federal do Ceará, Fortaleza, CE, Brazil
2Aegerion Pharmaceuticals, Cambridge, MA, USA
212 - Can Leptin Replacement Alter the Course of Disease in Patients With Acquired Generalized Lipodystrophy?
Eugenia Andres1, Elaine Chiquette2, Ana Antunes3, Taylor Salinardi, Phd3, and Mabel Ferraro1
1Pedro de Elizalde’ Children Hospital, Buenos Aires, Argentina
2Gelesis, Boston, MA, USA
3Aegerion Pharmaceuticals, Cambridge, MA, USA
213 - Hereditary Spastic Paraplegia Type 15 as a Rare Metabolic Disorder of Cellular Trafficking—2 New Cases
Vasilica Plaiasu1 and Claudia Maris2
1Insmc Alessandrescu-Rusescu, Bucharest, Romania
2National Institute of Neurology and Neurovascular Disorders, Bucharest, Romania
Hereditary spastic paraplegias (HSPs) are a heterogeneous group of inherited neurological disorders with the cardinal feature of a length-dependent axonopathy of corticospinal motor neurons. They are now mainly classified by their mapped genetic loci, SPG1 to SPG71. Mutations in ZFYVE26 gene are described as being responsible for SPG15. The majority of ZFYVE26 mutations are of loss of function. Different cellular pathogenic mechanisms have been suggested for SPG15. Some evidences suggested that SPG15 might be caused by impaired cellular trafficking. We identified two new families with members harboring mutations in the ZFYVE26 gene. Case 1, female, 37 years old, presented with symptoms since the age of 14 years that included progressive weakness of the lower limbs, spasticity, cramps, atrophy of the limbs (predominantly distal), no paresthesia, very dry skin, no seizures. Cerebral and cerebellar MRI was normal at the beginning of the disease, but later showed cerebral and cerebellar atrophy. The disease has progressed with degeneration of main functions: the gait was lost (she is now using a wheelchair), she has dysarthria, she can no longer use her hands, she has difficulties in writing, and she presents with muscular atrophy. Her two sisters (one of them is deceased) present/presented with the same symptomatology. Molecular genetic testing showed two heterozygous variants in the ZFYVE26 gene: c.2114dup (p.Glu706*) in exon 11 and c.5621+1G>A in intron 29. Case 2, female, 19 years old, from a consanguineous family, possessed cardinal features of HSP such as muscle weakness, gait disturbance, unsteady gait, fasciculation and myopathy starting from age of 17 years. Now she is no longer able to walk, but with normal intelligence. Molecular evaluation identified homozygous variant in the ZFYVE26 gene, c.2639T>C (p.Leu880Pro). Spastic paraparesis can be one of the multiple presentations of inborn errors of metabolism in children and adults and in some cases the symptom spastic paraparesis remains the only symptom for years; therefore, these metabolic causes should be included in the general diagnostic approach to sporadic spastic paraparesis. Genetic analysis of HSP genes represents the only way for diagnosis. Genetic counseling and prenatal and presymptomatic testing become possible options.
214 - Disturbances in the Respiratory Chain Complexes as a Possible Cause of Mitochondrial Dysfunction in Chronic Fatigue Syndrome
Line Weisbjerg1, Paula Fernandez-Guerra1, Ac Gonzalez Ebsen1, Jesper Mehlsen2, Niels Gregersen1, Louise Schouborg Brinth2, and Rikke Katrine Jentoft Olsen1
1Research Unit for Molecular Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
2Coordinating Research Centre, Bispebjerg Frederiksberg Hospital, Frederiksberg, Denmark
Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) is a debilitating illness with yet unknown etiology, making diagnosis and treatment challenging. Research in ME/CFS is hampered by heterogeneity in clinical expression and diagnostic criteria. Recent research has shown mitochondrial dysfunction with mitochondrial energy deficiency and oxidative stress in ME/CFS patients. We hypothesize that this mitochondrial dysfunction is caused by a vicious cycle of overproduction of reactive oxygen species, lipid peroxidation of the inner mitochondrial membranes, and damage to the respiratory chain complexes. We have collected peripheral blood mononuclear cells (PBMCs) and skin fibroblasts from six unrelated patients diagnosed with a severe form of ME/CFS. All patients are Caucasian females, 30-50 years old and with onset of symptoms after an infection or another immunogenic trigger. The aim of this study is to further investigate mitochondrial function and their role in ME/CFS, using PBMCs and an ex vivo model of skin fibroblasts. Mitochondrial function will be assessed using the extracellular flux analyzer (SeaHorse XFe-96), an instrument that enables real-time measurement of two central pathways to generate ATP in living cells: glycolysis and oxidative phosphorylation. Preliminary results on PBMCs from the six patients showed an enhanced metabolism, especially an enhanced glycolytic activity towards lactate production. Additionally, mitochondrial proton leak is increased. This could indicate a metabolic shift caused by oxidatively damaged mitochondrial membranes that affect mitochondrial respiration efficiency, supporting our hypothesis of mitochondrial dysfunction in ME/CFS. Besides the mitochondrial function assessment, lipid peroxidation will be quantified with image cytometry using the BODIPY® 581/591 undecanoic acid probe, which fluorescence upon lipid oxidation. Finally, the integrity of the respiratory chain complexes will be validated by blue native polyacrylamide gel electrophoresis. To follow up on our hypothesis, we will investigate whether we can improve mitochondrial function in cells harvested in our ME/CFS-patients by treatment with SS-31 peptides, a well-known cell-permeable antioxidant peptide that reduces intracellular free radicals and inhibits lipid peroxidation. Mitochondrial membrane integrity and function will be analyzed before and after treatment of skin fibroblasts with SS-31 peptides.
215 - Heterogeneous Clinical Spectrum of DNAJC12-Deficient Hyperphenylalaninemia: From Attention Deficit to Severe Dystonia and Intellectual Disability
Van Spronsen Francjan1, Nastassja Himmelreich2, Véronique Rüfenacht3, Heiner-Fokkema M.R. Rebecca1, Al-Owain Mohammed4, Ramzan Khusnooda4, Georg F. Hoffmann2, Nenad Blau2, and Beat Thöny3
1Division of Metab Dis, University Medical Center of Groningen, University of Groningen, Groningen, the Netherlands
2Dietmar-Hopp Metabolic Center, University Children’s Hospital, Heidelberg, Germany
3Division of Metabolism, University Children’s Hospital, Zurich, Switzerland
4Department of Medical Genet, King Faisal Specialist Hospital and Res Centre, Riyadh, Saudi Arabia
216 - Further Characterization of TBCK-Related Phenotype: Two Sibs With Severe Hypotonia, Intellectual Disability, and Epilepsy
Ana Silva1, Polona Le Quesne Stabej2, Paula Garcia1, Isabel Fineza3, Alessandro Rea2, Hywel Williams2, Philip Stanier4, Gudrun Moore4, Luísa Diogo1, and Sérgio Sousa5
1Metabolic Diseases Unit, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
2Gosgene, Ucl Great Ormond Street Institute of Child Health, London, United Kingdom
3Pediatric Neurology Unit, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
4Genetics and Genomic Medicine, Great Ormond Street Institute of Child Health, University College Lon, London, United Kingdom
5Medical Genetics Unit, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
217 - Phenotypic and Molecular Characterization of a Third Patient With Primary COQ10 Deficiency Caused by COQ7 Mutations
Marwan Shinawi and Laura Duque Lasio
Washington University School of Medicine, St. Louis, MO, USA
218 - Severe Scoliosis in a Colombian Patient With Juvenile Hypophosphatasia: Case Report
Ana Maria Zarante Bahamón
Instituto de Ortopedia Infantil Roosevelt, Bogotá, Colombia
Hypophosphatasia (HPP), (OMIM 146300, 241500, 241510) is a rare genetic pathology characterized by deficiency in bone and dental mineralization with an approximate incidence of 1: 100 000 to 1: 300 000 for severe forms and being larger for forms Moderate and mild, the latter probably underdiagnosed. It is caused by deficiency in non-specific alkaline phosphatase bone activity (TNSALP) due to mutations in the ALPL gene. To date, six clinical forms have been described according to the age at onset of symptoms and severity: perinatal lethal, perinatal benign, infantile, juvenile, adult and odontohypophosphatasia. Its clinical expressiveness is highly variable from in utero death to spontaneous loss of teeth without bone involvement. The diagnosis is based on the measurement of serum alkaline phosphatase (FA) and the sequencing of the ALPL gen. We describe the case of a Colombian patient with juvenile onset hypophosphatasia in which her main manifestation was the presence of severe scoliosis.
F) Phenylketonuria; General (219 to 280)
219 - The Effect of Growth Hormone Therapy on Plasma Phenylalanine Level in Patient with Phenylketonuria: Case Report
Engin Kose1, Sezer Acar2, Korcan Demir2, Afig Berdeli3, and Nur Arslan1
1Dokuz Eylul University Pediatric Metabolism, Izmir, Turkey
2Dokuz Eylul University Pediatric Endocrinology, Izmir, Turkey
3Ege University Molecular Medicine Laboratory, Izmir, Turkey
220 - Investigation of the Factors That Affecting Adherence to Dietary Treatment in Patients With Phenylketonuria
Idil Akay Haci1, Pelin Teke Kisa2, Engin Kose2, and Nur Arslan2
1Department of Pediatrics, Dokuz Eylul University, İzmir, Izmir, Turkey
2Division of Pediatric Metabolism and Nutrition, Dokuz Eylul University, Izmir, Turkey
221 - Degradation of Tyrosine by Intestinal Microbes Contributes to Reduced Bioavailability of Tyrosine from Amino Acid Compared With Glycomacropeptide Medical Foods in Phenylketonuria
Denise Ney1, Sangita Murali1, Bridget Stroup1, Nivedita Nair1, Emily Sawin1, Frances Rohr2, and Harvey Levy3
1University of Wisconsin–Madison, WA, USA
2Boston Children’s Hospital, Madison, WA, USA
3Boston Children’s Hospital, Boston, MA, USA
222 - Patient Survey on PKU Treatment
Christine Brown1 and Uta Lichter2
1National Pku Alliance, Tomahawk, WI, USA
2Childen’S Hospital Pittsburgh, Pittsburgh, PA, USA
Phenylketonuria (PKU) is a rare metabolic disorder characterized by impaired conversion of phenylalanine (Phe) to tyrosine. If left untreated, the resultant accumulation of excess blood Phe can cause physiological, neurological, and intellectual disabilities. The National PKU Alliance (NPKUA) conducted a survey of its membership to assess current health status and interest in new treatments for PKU. Of the 625 survey respondents, less than half (46.7%) reported blood Phe within (120-360 μmol/L)—the range recommended by the American College of Medical Genetics and Genomics (ACMG). The survey results also showed that younger (≤ 18 years) subjects were about 3-times as successful in keeping their blood Phe concentrations within the recommended clinical range compared with adults. Blood Phe over 360 μmol/L was reported in one-quarter (25.5%) of ≤ 18-year-old subjects and almost two-thirds (61.5%) of > 18-year-old subjects. A little more than half (51.7%) of respondents reported having difficulty in managing their PKU, including the maintenance of a Phe-restricted diet. Subjects with PKU desire new treatments that would allow them to increase their intake of natural protein, discontinue or reduce their intake of Phe-free medical food and low-Phe foods, improve their mental health (including depression and anxiety), and reduce blood Phe concentrations. Respondents preferred oral administration of any newly developed therapies and, in general, disliked therapeutic injections. Injections at home were preferred over injections at a clinic. Payers, government agencies, clinicians, and industry partners should consider patient input when developing and approving new therapies and treatments for PKU.
223 - International PKU Patient Registry
Christine Brown1, Olaf Bodamer2, Harvey Levy2, and Susan Waisbren2
1National Pku Alliance, Tomahawk, WI, USA
2Boston Children’s Hospital, Boston, MA, USA
The implementation of an outcomes oriented patient registry for phenylketonuria (PKU) expands our knowledge basis on the variability of the clinical phenotype, identifies unmet needs and guides the scientific community in the development of novel therapies. The NPKUA Patient Centered Outcome Registry, launched in January 2017 is a global registry for patients with PKU. The registry will collect information from families/participants who are affected by PKU and who are interested in participating in future research. The registry utilizes a web- based interface (https://pku.iamrare.org) to maximize accessibility to participating families and clinics at a global scale. Registry participants will automatically be enrolled in the Global Rare Disease Registry (GRDR), and their de-identified information aggregated with information from other rare diseases. The purpose of the NORD Platform & GRDR is to enable analyses of data across many rare diseases and to facilitate clinical trials and other studies. Third parties may seek access to data in the PKU Patient Registry. Third parties may include, but are not limited to, researchers or companies conducting retrospective studies or conducting research and/or clinical trials on new therapies and will only be granted access to registry information upon review and approval of the Registry Advisory Board. Utilizing a survey format, the PKU Patient Registry collects data on long-term metabolic control and management, co-morbidities and co-medication, general health and life style, social-economic factors and PKU genotypes. Access to Phenylhydroxylase gene sequencing is facilitated through collaboration with Baby Genes (
224 - PKU Knows No Borders
Norman Adams1 and Christine Brown2
1Canada Pku And Allied Disorders, Toronto, Canada
2National Pku Alliance, Tomahawk, WI, USA
PKU knows no borders. PKU patient advocacy organizations representing Australia, Canada, Europe, and the United States came together last year and agreed it is time to make history in PKU by forming a global association of PKU organizations representing the diverse population of our world-wide community. This initial group sees the formation of such an organization as a critical need in the PKU community as newborn screening expands, pressure for access to medical foods and other treatments increases and to more efficiently handle requests for assistance from many parts of the world. This new global umbrella organization would have the following priorities: 1. Mentor new countries and offer them guidance, best practices, and support on how to form an engaged patient/family group in their country/jurisdiction that is sensitive to their experiences, culture, and language(s). 2. Create a global platform for advocacy that includes access to newborn screening, clinical care, and treatments. 3. Foster collaboration among researchers, scientists, and clinicians to move the basic science and research forward to inform access to current treatment and accelerate new knowledge discovery of PKU and future treatments. An organizing meeting for the international group will be held July 2017 with PKU patient organizations from Canada, the United States, the United Kingdom, Australia, Germany, Turkey, China, Brazil, Mexico, Argentia and Chile. We would like to announce the formation of this group at ICIEM.
225 - Phenylalanine Hydroxylase: Molecular Study Implementation in Chile
Valerie Hamilton1, Lorena Santa María1, Karen Fuenzalida1, Paulina Morales1, Belen Pérez2, and Veronica Cornejo1
1Institution of Nutrition and Food Technology Inta, University of Chile, Santiago, Chile
2Centro de Diagnóstico de Enfermedades Moleculares (Cedem) Universidad Autónoma de Madrid, Spain., Madrid, Spain
226 - What is the Optimal Dosage of LNAA Combined With a Semi-Free Diet for Patients With PKU?
Kirsten Ahring1, Jens Rikardt Andersen2, and Lisbeth Birk Moller1
1Kennedy Centre, Copenhagen University Hospital, Glostrup, Denmark
2Copenhagen University, Copenhagen, Denmark
227 - What is the optimal dosage of Large Neutral Amino Acid when combined with a semi-free diet for patients with Phenylketonuria?
Kirsten Ahring1, Jens Rikardt Andersen2, and Lisbeth Birk Moller1
1Kennedy Centre, Copenhagen University Hospital, Glostrup, Denmark
2Copenhagen University, Copenhagen, Denmark
228 - Post-Prandial Amino Acid Profile in Children with Phenylketonuria Taking CGMP-AA or Phe-Free Protein Substitutes
Anne Daly1, Satnam Chahal1, Sharon Evans1, Alex Pinto1, Cerys Gingell2, Júlio Rocha3, and Anita Macdonald1
1Birmingham Women’s and Children’s Hospital, Birmingham, United Kingdom
2Nottingham University Hospital, Queens Medical Centre, Nottingham, United Kingdom
3Centro Di Genetics Medica, Centro Hospitalar do Porto (Chp) Proto, Porto, Portugal
229 - Blood Phenylalanine Reduction Corrects Monoamine Neurotransmitter Deficiencies and Improves Behavioral Performance but has no Effect Upon Cognitive Disability in Adult Mice With Phenylketonuria
Cary O. Harding1, Shelley Winn1, Tanja Scherer2, Beat Thöny2, Ming Ying3, Aurora Martinez3, Sydney Weber1, and Jacob Raber1
1Oregon Health & Science University, Portland, OR, USA
2University of Zurich, Zurich, Switzerland
3University of Bergen, Bergen, Norway
Central nervous system (CNS) deficiencies of the monoamine neurotransmitters dopamine and serotonin have been implicated in the pathophysiology of neuropsychiatric dysfunction in human phenylketonuria (PKU). In this study, we confirmed the occurrence of brain dopamine and serotonin deficiencies in association with severe behavioral alterations and cognitive impairments in hyperphenylalaninemic C57BL/6-Pahenu2/enu2 mice, a model of human PKU. Phenylalanine-reducing treatments, including either dietary phenylalanine restriction or liver-directed gene therapy, initiated during adulthood were associated with increased brain monoamine content along with improvements in nesting behavior but without a change in the severe cognitive impairments exhibited by these mice in the water maze. Following the behavioral and cognitive testing, the mice were euthanized for biochemical analyses. Brains of Pahenu2/enu2 brain showed significant reductions in the protein abundance and maximally stimulated activities of tyrosine hydroxylase (TH) and tryptophan hydroxylase (TPH), the rate limiting enzymes catalyzing dopamine and serotonin synthesis respectively, in comparison to those seen in wild type animals. Phenylalanine-reducing treatments initiated during adulthood did not affect brain TH or TPH content or maximal activity. Despite this apparent fixed deficit in striatal TH and TPH activities, initiation of phenylalanine-reducing treatments yielded substantial correction of brain monoamine neurotransmitter content suggesting that phenylalanine-mediated competitive inhibition of already constitutively reduced TH and TPH activities is the primary cause of brain monoamine deficiency in Pahenu2 mouse brain. We propose that CNS monoamine deficiency may be the cause of the reversible adverse behavioral effects associated with chronic hyperphenylalaninemia in Pahenu2 mice, although phenylalanine-reducing treatments initiated during adulthood are unable to correct the neuropathology and attendant cognitive deficits that develop during juvenile life in late-treated Pahenu2 mice.
230 - Treatment Adherence During Childhood in Individuals With Phenylketonuria: Early Signs of Treatment Discontinuation
Maria Ignacia García1, Gabriela Araya1, Soledad Coo2, Susan Waisbren3, and Alicia de La Parra1
1Labgem Inta, Universidad de Chile, Santiago, Chile
2Centro de Apego Y Regulación Emocional Care, Universidad Del Desarrollo, Chile, Santiago, Chile
3Division of Genetics and Genomics, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
231 - Hyperphenylalaninemias, Anthropometric Evaluation, and Body Composition of a Group of Patients, Havana, Cuba
Georgina Maria Zayas Torriente1, Dainet Abreu Soto1, Juana Maggie Torriente Valle Torriente Valle1, Yoandry Alfonso, Díaz Fuentes1, Hilda Noemi Chávez Valle1, Santa Caridad González O’Farrill1, Ursula Hilaria Carrillo Estrada2, Adaljiza Torriente Fernández3, and Laritza Martínez-Rey4
1Instituto Nacional de Higiene, Epidemiología Y Microbiologia, La Habana, Cuba
2Hospital Pediátrico Borrás -Marfan, La Habana, Cuba
3Hospital Clínico Quirúrgico Freyre de Andrade, La Habana, Cuba
4Centro Nacional de Genética Médica, La Habana, Cuba
Hyperphenylalaninemias are caused by total or partial deficiency of the enzyme Phenylalanine hydroxylase. They comprise several conditions that differ from one to another, both clinically and biochemically, with classical Phenylketonuria being the most common entity. It is considered the most frequent metabolic disease with appearance after the neonatal stage. Symptoms usually occur after 6 months, presenting retarded psychomotor development. The diagnosis before a month of life allows to establish the appropriate therapy and to prevent neurological deficits. The nutritional evaluation is part of the treatment and is performed monthly in the consultation through clinical, anthropometric, biochemical and dietary indicators.
232 - Clinical Characteristics of the Adult Population With Phenylketonuria Attended at the University Hospital Virgen del Rocio
Eva Venegas Moreno, Suset Dueñas Disotuar, Elena Dios Fuentes, Maria Bueno-Delgado, Antonio Gonzalez Meneses, Cecilia Gallego Casado, and Alfonso Soto Moreno
University Hospital Virgen Del Rocio, Seville, Spain
233 - Mechanistic Aspects of Phenylketonuric Bone Disease
Steven Dobrowolski1, Harry Blair1, Irina Tourkova1, Lyubov Kublo1, Kayla Spripik1, and Lisa Robinson2
1University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
2West Virginia University School of Medicine, Morgantown, VA, USA
Phenylalanine hydroxylase (PAH)-deficient phenylketonuria (PKU) is a treatable amino acidopathy that originally motivated newborn screening. Among the least investigated aspects of PKU is the bone phenotype. Human and rodent studies have established decreased bone mass to be observed in PKU which was originally attributed to dietary intervention; however, recent investigations indicate the bone phenotype is part of the disease pathology. The mechanism of PKU bone disease is poorly characterized but a definitive correlation with phenylalanine (PHE) management is not fully established. While PAH expression has been described in bone, it is minor compared to that observed in liver and kidney. We hypothesized that bone cells in the Pahenu2 mouse might have a direct bone defect unrelated to PHE levels based on findings that mesenchymal stem cells (MSC) or osteoblasts express PAH (p = 0.04), which thus might prevent effects of PHE on MSC differentiation and bone formation. The Pahenu2 mouse was assessed by static and dynamic histomorphometry; which showed bone density in PKU mice decreased 33% relative to the C57BL/6 background strain (P = .03, n = 4); bone volume/total volume was similarly decreased; trabecular thickness was unchanged while trabecular spacing increased (P = .05). On dynamic histomorphometry, the labeled surface did not change but mineral apposition decreased by 20%, p < 0.001. These data suggest a mineralization defect. We tested this hypothesis by isolating MSC from C57BL/6 and Pahenu2 mice, and subsequently inducing in vitro bone differentiation. MSC from both C57BL/6 and Pahenu2 formed normal bone nodules when cultured in standard bone differentiation medium containing ascorbate and beta glycerol phosphate. However, addition of 1000 µM PHE to differentiation media prevented MSC from both C57BL/6 and Pahenu2 from forming bone. We conclude that the PKU bone phenotype is mediated by PHE-directed interference with MSC maturation, and that the low-level endogenous PAH is insufficient to protect developing bone. At least in vitro, where sustained 1000 µM PHE is practical, the bone effect correlates directly with PHE levels, independently of MSC being derived from C57BL/6 or homozygous Pahenu2 animals. That MSC from wild type animals behave identically to MSC from Pahenu2 when cultured in media containing PHE, provides evidence that PHE toxicity is a mediator of PKU bone disease.
234 - Consistent Epigenetic Findings Across Human PKU, Mouse PKU, and Mouse MPKU
Steven Dobrowolski and Kayla Spripik
University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
Phenylalanine hydroxylase deficient phenylketonuria (PKU) is a rare, treatable amino acidopathy. The maternal PKU syndrome (MPKU) is a somatic embryopathy whereby in utero PHE toxicity affects the offspring of PKU-affected women. Despite >50 years of investigation, little has been characterized regarding PHE toxicity and pathological mechanisms wherein neurologic phenotypes are realized in either PKU or MPKU. Based on unequivocal data demonstrating epigenomic dysfunction owing to chemically diverse toxic exposures, we investigated patterns of DNA methylation as a response to PHE intoxication in human PKU, mouse PKU, and mouse MPKU. In homozygous Pahenu2 mice investigations were performed in brain tissue of hyperphenylalaninemic and PHE restricted animals. Using Pahenu2 to model MPKU, investigation was performed in heterozygous E18 offspring of either hyperphenylalaninemic or PHE controlled females. Human PKU was investigated in mixed leukocytes of classical PKU patients that were either exceedingly well controlled or therapy noncompliant. Methylated DNA immunoprecipitation and genomic sequencing were applied to assess patterns of DNA methylation. Consistent among all systems is significantly increased aberrant DNA methylation in the context of uncontrolled hyperphenylalaninemia and reduced but not fully eliminated aberrant methylation when PHE is well managed. Non-coding RNA genes and particularly microRNA genes are frequent targets of aberrant methylation across all systems. A common target is the microRNA gene cluster within the imprinted Dlk1-Dio3 locus. MiRNA gene demethylation causes upregulation of their expression which has downstream impact upon the expression of protein coding genes having neurologic function. Other consistent elements include genes involved in glutaminergic neuron function. Even in untreated classical PKU, improvement is realized after establishing PHE control which suggests a reversible mechanism characteristic of epigenetic systems. We posit that epigenetic mechanisms underlie elements of neurologic dysfunction brought on by PHE toxicity. PKU management has singularly focused upon PHE reduction but never the consequence(s) of PHE intoxication. We suggest neurologic aspects of both PKU and MPKU may be treatable by repurposing existing epigenome targeting drugs.
235 - A Pig Model of PAH-Deficient Phenylketonuria
Steven Dobrowolski1, Erik Koppes2, Bethany Redel3, Kristen Skvorak1, Lina Ghaloul-Gonzalez2, Megan Yates2, Marie Johnson2, Dale Lewis4, Susanne Gollin4, Martine Yerle5, Lee Spate3, Joshua Benne3, Stephanie Murphy3, Melissa Samuel3, Eric Walters3, Sarah Hansen6, Kevin Wells3, Jerry Vockley2, Randall Prather3, and Robert Nicholls2
1University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
2Children’s Hospital of Pittsburgh of Upmc, Pittsburgh, Pennsylvania, USA
3College of Agriculture and Natural Resources, University of Missouri, Columbia, Missouri, USA
4Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
5Génétique Physiologie Et Système D’Elevage, Castanet-Tolosan, France
6Office of Animal Resources, University of Missouri, Columbia, MI, USA
Phenylalanine hydroxylase deficient phenylketonuria (PKU) is the paradigm for a treatable inborn error of metabolism which motivated prospective newborn screening. The Pah enu2 mouse is the standard PKU animal model possessing the c.835T>C (p.F263 S) Pah mutation and hyperphenylalaninemia consistent with classical disease. While Pah enu2 biochemically models human disease, clinical manifestations of human PKU are poorly recapitulated. To create a PKU model with greater clinical relevance to human disease, CRISPR/Cas9 gene editing was applied to create a PKU pig model. Candidate guide RNAs (gRNA), for deletion of exon six in the pig PAH gene, were optimized in pig: rodent somatic cell hybrids. PCR demonstrated efficient editing (deletion, inversion) of the target region. An optimized pair of gRNAs and mRNA encoding Cas9 were injected into pig zygotes that were subsequently cultured in vitro prior to implantation into surrogate sows from which two F1 female animals (116 -1 and 116-2) were born. The F1 animals were characterized by molecular, biochemical, and clinical means. PCR studies confirmed that animal 116 -1 contained two edited PAH alleles, one with the expected 1.2 kb deletion of exon 6, while the second allele contained a 4.1 kb deletion encompassing exons 6 and 7. Animal 116-2 had a single edited allele with the expected 1.2 kb exon 6 deletion. Biochemically 116 -1 demonstrated blood hyperphenylalaninemia of 2,063 µM, urine phenylalanine of 12.24 mM/gram creatinine, and excretion of organic acid metabolites (N-acetylphenylalanine, phenyllactate, phenylpyruvate) consistent with PKU. Animal 116-2 has blood PHE in the normal range (114 µM), undetectable PHE in urine, and excreted no PKU associated organic acids. Clinically 116 -1 is hypopigmented and growth retarded while the carrier 116-2 has normal growth and pigmentation. These animals represent the first large animal model of PAH deficient PKU, and will provide a model to study PKU pathophysiology and serve as a preclinical model to assess potential therapeutic interventions.
236 - Daily Life, Dietary Practices, and Health Conditions of Adult PKU Patients: A Multi-Center Cross-Sectional Study
Annemarie Klimek1, Christoph Baerwald2, Martin Schwarz3, Frank Rutsch4, Klaus Parhofer5, Ursula Plöckinger6, Margret Heddrich-Ellerbrok7, Klaus Schöne8, Markus Ott9, and Julia Hennermann10
1Villa Metabolica, University Medical Center Mainz, Mainz, Germany
2University Medical Center Leipzig, Leipzig, Germany
3Surgery Dr. Schwarz, Kaarst, Germany
4University Medical Center Münster, Münster, Germany
5University Medical Center München, München, Germany
6Charité University-Hospital Berlin, Berlin, Germany
7Amedes Specialist Center Hamburg, Hamburg, Germany
8University Medical Center Mainz, Mainz, Germany
9Nutricia Gmbh, Metabolics Expert Center Dach, Bad Homburg, Bad Homburg, Germany
10Villa Metabolica University Medical Center Mainz, Mainz, Germany
237 - Blood Phenylalanine Control in Phenylketonuria in One UK Centre: Audit From 2010 to 2016
Alex Pinto1, Anita Macdonald1, Anne Daly1, Sharon Evans1, Júlio Rocha2, and Anita Macdonald1
1Birmingham Women’s and Children’s Hospital, Birmingham, United Kingdom
2Centro de Genética Médica, Centro Hospitalar do Porto (Chp), Porto, Portugal
238 - Oxidative Stress in Cuban Patients With Phenylketonuria
Jiovanna Contreras-Roura, Laritza Martínez-Rey, Gretel Riverón-Forment, Guillermo Antonio Mairena-Larios, Olivia Martínez-Bonne, and Gisselle Lemus-Molina
National Center of Medical Genetics, La Habana, Cuba
Oxidative stress has been thought to be involved in the pathogenesis of several inborn errors of metabolism including phenylketonuria (PKU). The aim of this study was to investigate some redox status biomarkers in patient with PKU treated with a diet restricted of phenylalanine. We performed an observational case–control study. We included a total of 13 patients of both genders and 16 healthy children as controls from Havana city. Informed consent was obtained from all parents of children who participated in this study. Plasmatic levels of malondialdehyde, advanced oxidation protein products, total thiols and intraerythrocytic enzymatic activities of Cu/Zn Superoxide Dismutase and Catalase were determined by spectrophotometric methods. It was found high plasmatic levels of total thiols in PKU patients compared to controls. The activity of antioxidant enzymes tested the ratio of Cu/Zn superoxide dismutase to catalase and oxidative damage markers in PKU patients were not different from the control group. The increase in thiols groups concentrations and the low levels of oxidized products found suggest the existence of mild oxidative conditions in PKU patients with a restrictive diet.
239 - Studying the Effect of Large Neutral Amino Acid Supplements on Oxidative Stress
Burcu Kumru1, Burcu Ozturk Hismi2, Davut Sinan Kaplan3, and Hakim Celik4
1Gaziantep Children’s Hospital, Division Nutrition and Diet, Gaziantep, Turkey
2Tepecik Research Hospital, Division Metabolic Disorders, Izmir, Turkey
3Gaziantep University, Department of Physiology, Gaziantep, Turkey
4Harran University, Department of Physiology, Sanliurfa, Turkey
240 - Chilean Experience in the Conventional Treatment of Children with Classic PKU Diagnosed by Newborn Screening Program: 24 years of Experience
Castro Chaves, Carolina Arias, and Juan Francisco Cabello
Inta, Universidad de Chile, Santiago, Chile
241 - Hyperphenylalaninemia due to Dihydropteridine reductase (DHPR) Deficiency: Experience in Diagnosis and Management in the Social Security of Peru
Milagros Dueñas-Roque, Marco Morales-Acosta, Martha Lavado-Ariza, María Teresa Bojorquez-Rivera, Ana Cecilia Bonilla Suárez, Mercedes Arteaga-Cano, and Ana Prötzel-Pinedo
Hospital Nacional Edgardo Rebagliati Martins, Lima, Peru
242 - A Pharmaceutical Technology Applied to Medical Food Engineered to Allow Physiological Absorption of Amino Acids (AA) for Phenylketonuria
Gaia Piraccini1, Nadia Giarratana1, and Guglielmo Gallina2
1Apr Applied Pharma Research, Balerna, Switzerland
2Vetspin, Bologna, Italy
A pharmaceutical technology has been applied to a mix of amino acids (AAs) with the double aim of fully masking their taste, odor and eliminating aftertaste as well as of prolonging their release in the gut, allowing a physiological absorption. A pre-clinical study investigated the kinetics of two AA mixes engineered (engP-1 and engP-2) to allow a prolonged and gradual release of the AAs compared to the same mix of free (nonengineered; n-engP) AAs and to casein. In a cross-over design, 4 groups of female pigs (2 animals/group) received the 4 oral products (engP-1, engP-2, n-engP, and casein) in single dose, with wash-out periods ≥ 48 h. The administered dose was of 0.8 g AA/kg body weight. Blood sampling was obtained before (0.75, 0.50, and 0.25 hours) and after (0.25, 0.50, 0.75, 1, 1.25, 1.50, 2, 2.50, 3, 4, and 5 hours) each administration. AA concentrations were determined by a validated HPLC-MS/MS method. The following parameters were calculated: area under the concentration/time curve (AUC0-last), peak concentration (Cmax), time to Cmax (Tmax) and last measured concentration (Clast). Cmax of the measured AAs (n = 13) in engP-1 and engP-2 resulted lower, 17% and 18% respectively, compared to the n-engP. This reduction in Cmax was conspicuously higher and statistically significant for essential AAs (EAAs; P < .01), large neutral AAs (LNAAs; P < .01) and branched chain AAs (BCAAs; P < .01), indicating that the applied technology is able to reduce the typical absorption peak of free AAs, allowing to obtain products with Cmax values very similar to casein, a reference food protein. As expected, AUC0-last of engP-1 and engP-2 was not statistically different from the AUC0-last of n-engP. AUC data indicate that the amount of absorbed AAs in engP-1 and engP-2 is comparable to that of n-engP, although complete AA absorption should be observed over >5 hours. The dissolution tests of all AA mixes showed a good in-vitro/in-vivo relationship. The technology conferred taste-, odor-, and aftertaste-free properties after initial in-house tests. Tests in healthy volunteers and patients are planned. Application of a pharmaceutical technology to AA mixes for PKU can bring new and important organoleptic improvements theoretically conducive to optimal adherence to dietary treatment as well as potentially leading to clinically relevant benefits based on a more physiological absorption of AAs.
243 - Adolescents in the PKU Clinic
Karin Enggaard
Kennedy Center, Rigshospitalet, Glostrup, Denmark
Phenylketonuria (PKU) is an inherited autosomal recessive disease. Metabolic control can be difficult to achieve especially for adolescents. Literature discusses the importance to meet the growing independence of young patients and increasingly adult behavior, as the risk for adolescents to ‘drop out’ of the medical care system if the patient is not understood. Transition from child to adult health care is a particular vulnerable period for young patients with inborn metabolic diseases as PKU. In Denmark, there is only one clinic that offers the very specialized knowledge about PKU. Since 1967 Center for PKU has handled the treatment and follow up visits of the patients in order to stay mentally well functioning by learning and guidance the individuals in the very restricted lifelong low protein diet. In order to understand the adolescents with PKU in Center for PKU, twenty-seven questionnaires were sent by email to PKU patients aged between seventeen and twenty-one years in age. Seven adolescents with PKU (4 females and 3 males) answered the questionnaire. Questions as: “Do the professionals talk about things that you find of your interest?” and “is it an advantage or disadvantage that you meet the same environment and staff as when you were a child and that there is a knowledge of your childhood?” In a combination with observations in the clinic the results points to that experience and knowledge about the patients’ childhood and life amongst the employees in the clinic is crucial to maintain the important relationship between the professionals and the adolescents. If not, the patients express less feeling of safety and continuity. Furthermore, they express a feeling of neglect when they meet organizational changes and many different professionals in the clinic. In conclusion, PKU adolescents do not find it beneficial and necessary to make a transition to an adult clinic in order to be met and understood as an adolescent.
244 - Case Report: Study of the Clinical Significance of the 168 + 19 T> C Mutation
Soledad Méndez, Aida Lemes, and Cecilia Queijo
Laboratorio de Pesquisa Neonatal, Montevideo, Uruguay
245 - A Tool for Allelic and Genotype-Based Prediction of Metabolic Phenotypes in PKU
Sven F Garbade, Nan Shen, Friedrich Trefz, Nastassja Himmelreich, Dorothea Haas, Georg F. Hoffmann, Peter Burgard, and Nenad Blau
Dietmar-Hopp Metabolic Center and Centre for Pediatrics and Adolescent Medicine, University Hospital, Heidelberg, Germany
246 - Maternal Phenylketonuria and Offspring Outcomes: A Single Centre Experience
Sabrina Paci, Ambra Maria Morgano, Valentina Rovelli, Alice Re Dionigi, Elisabetta Salvatici, Graziella Cefalo, Chiara Montanari, Juri Zuvadelli, and Giuseppe Banderali
Pediatric Department, San Paolo Hospital, University of Milan, Asst Santi Paolo e Carlo, Milan, Italy
Phenylketonuria (PKU) is an autosomal recessive inborn error of amino acid metabolism. Elevated phenylalanine (Phe) levels in a pregnant woman with PKU may result in “Maternal PKU Syndrome (MPKU),” an embryopathy whose clinical phenotypes include spontaneous abortion, preterm labor, intrauterine growth retardation-IUGR, small for gestational age-SGA, microcephaly, psychomotor delay, facial dysmorphism, cardiopathy and associated malformations, regardless fetus’ genetic PKU status. While PKU newborns can now be treated by early dietary and/or pharmacological intervention, damage caused to the fetus by mother’s high Phe levels is irreversible. More favorable outcomes are observed when Phe levels are maintained within “safe ranges” prior to conception or promptly as an unplanned pregnancy is recognized. Newborn screening program for PKU was introduced in Italy by law in 1992; its success resulted in a large number of women with PKU now of childbearing age at risk of having children with MPKU. Purpose of this study was to describe a female PKU group in charge at our Metabolic Department and to evaluate their obstetric and neonatal complications’ incidence. 24 PKU women for a total number of 39 pregnancies were followed: 15 were diagnosed by newborn screening, 2 late (> 1 y.o.) diagnosed and 7 after labor. Among all 39 pregnancies, it was described: spontaneous abortion (15.3%), IUGR (2.5%), and premature labor (2.5%). Within the total of 33 newborns, we found microcephaly (24.2%), SGA (6%), facial dysmorphisms (9%), cardiopathy (6%), labiopalatal cleft (3%), and psychomotor delay (18.1%). Pregnancies of women with Phe values consistently <240 μmol/L (Group A) compared to ones with >240 μmol/L (Group B) showed a statistically significant difference referred to outcomes, with significantly higher neonatal complications in Group B (P = .0013). This was confirmed considering both obstetric complications as a whole (P = .010) or spontaneous abortion isolated (P = .027). Concluding, beneficial effects of newborn screening must not be overshadowed by possible birth defects due to maternal PKU. Prompt identification of PKU females of childbearing age combined with intensive patient counseling throughout preadolescence, adolescence, and adulthood is mandatory, optimizing care to ensure benefits for the next generation.
247 - Finger Prick to Finger Tip: Novel Use of Technology to Improve Patient Communication in PKU
Anne Clark1, Deirdre Deverell2, Margaret Macauley1, Peter Branagan3, Nicola Newcombe3, Ellen Crushell1, Joanne Hughes1, Ina Knerr1, and Ardeshir Monavari1
1National Centre For Inherited Metabolic Disorders, Children’s University Hospital, Dublin, Ireland
2Paediatric Laboratory Medicine, Children’s University Hospital, Dublin, Ireland
3Information and Technologies Department, Children’s University Hospital, Dublin, Ireland
248 - Development of Genetically Engineered E. coli Nissle Strains for the Treatment of Phenylketonuria and Maple Syrup Urine Disease
Yves Millet, Vincent Isabella, Kip West, Binh Ha, Mary Castillo, Dean Falb, Paul Miller, and Caroline Kurtz
Synlogic, Cambridge, MA, USA
The fields of synthetic biology and microbiome research expanded greatly over the last decade and enables the development of new therapeutic strategies, using engineered microbes that operate from within the gut. Phenylketonuria (PKU) and maple syrup urine disease (MSUD), two inborn errors of metabolism disorders (IEMs) where a toxic substrate is present in the intestinal lumen, are potential therapeutic targets for this approach. PKU, caused by a defect in phenylalanine hydroxylase (PAH) activity, is characterized by the accumulation of systemic phenylalanine (Phe) that can lead to severe neurological deficits unless patients are placed on a strict low-Phe diet. As an alternative treatment, Escherichia coli Nissle (EcN), a well-characterized probiotic, was genetically modified to efficiently import and degrade Phe (SYN-PKU). The coupled expression of a Phe transporter with a Phe ammonia lyase (PAL) allows rapid conversion of Phe into trans-cinnamic acid (TCA) in vitro. Experiments conducted in the enu2−/− PKU mouse model showed that the oral administration of SYN-PKU is able to blunt an increase in blood Phe level triggered by subcutaneous Phe injection by 49% compared to controls. To support further the development of SYN-PKU, hippuric acid (HA) was examined as a urine biomarker of in vivo activity. Analysis of enu2−/− mice dosed orally with TCA demonstrated that 88% of gavaged TCA was excreted in the urine as HA, and enu2−/− mice treated with SYN-PKU showed greatly elevated urine HA levels, concomitant with a significant decrease in their blood Phe level. In addition to SYN-PKU, a second EcN strain was genetically engineered to rapidly import and degrade branched-chain amino acids (BCAAs) for the treatment of MSUD (SYN-MSUD). MSUD is caused by a defect in branched-chain ketoacid dehydrogenase activity leading to the toxic accumulation of BCAAs and their ketoacid derivatives. The controlled expression in SYN-MSUD of two BCAA transporters and three BCAA-degrading enzymes result in the efficient degradation of BCAAs into branched-chain alcohols. In a mouse model of MSUD, the oral delivery of SYN-MSUD suppressed the increase in blood BCAAs level induced by a high-protein challenge and prevented the associated moribund phenotype, as measured by locomotor activity. In conclusion, the in vivo therapeutic effects observed with SYN-PKU and SYN-MSUD support the further evaluation of engineered microbes as promising approaches to treat serious IEMs.
249 - Phenylketonuria and Calcium Consumption: Case Report
Izabella Zacarias1, Marcela Miranda2, Rita Helena Martins3, Gisele Luca3, Louise Pinto3, and Francisca Ligia Carvalho3
1Hospital Infantil Joana de Gusmão, Florianópolis, SC, Brazil
2Instituto de Ensino, Pesquisa e Gestão Em Saúde, Ipgs, Porto Alegre, RS, Brazil
3Hospital Infantil Joana de Gusmão, Florianopolis, SC, Brazil
The Phenylketonuria is the metabolism’s innate error most found in the brazilian population and it is related to the metabolism of the amino acid phenylalanine. Thanks to a restrictive diet, some foods that are sources of calcium, like milk, for example, are removed from the patient’s diet, potentially causing diseases of bone demineralization. Because of this, the goal of this report was to evaluate calcium consumption of this patient. After nine months of study it can be noted a diminution of sérico calcium however it is judged necessary more studies about the relationship of consumption of this mineral and dietary restriction as a consequence of phenylketonuria. The study was conducted with a student answered in outpatient chronic patients of the Hospital Infantil Joana de Gusmão, classical phenylketonuria, diagnosed in the newborn screening, 7-year-old male, a resident of the city of Florianópolis, State of Santa Catarina. An only child, living with parents who are cousins. Queries are performed according to Protocol for patients with phenylketonuria. Lack of adherence to treatment and low consumption of food sources can lead to a lack of calcium, a mineral with extensive participation in the growth and development of children and adolescents with Phenylketonuria. On this concern, this study shows that low calcium consumption can interfere significantly in bone metabolism but should be conducted more studies in children with this innate error of metabolism.
250 - Short-Term Biological Variance of Phenylalanine in Patients With Phenylketonuria
Murray Potter1, Amy Pender1, Erica Langley2, and Michael Geraghty2
1Mcmaster Children’s Hospital, Hamilton, Canada
2Children’s Hospital of Eastern Ontario, Ottawa, Canada
Control of blood phenylalanine (PHE) levels is the primary goal in managing phenylketonuria (PKU). Both the overall exposure to PHE and the variation in PHE are thought to contribute to long-term neurocognitive outcome. The objective of this study was to measure the diurnal variation of PHE in patients ≥4 years of age and to examine the interaction of dietary patterns with PHE levels. Four groups were studied: The first two groups were patients with PKU (at least 1 documented PHE level ≥600 µM) who were treated with diet alone. These were divided into “High PHE” (n = 6) and “Target PHE” (n = 12) groups based on blood PHE levels on the day of the study (≥600 µM or <600 µM, respectively). The “Sapropterin” group (n = 9) was PKU patients treated with diet plus sapropterin dihydrochloride (KUVAN® BioMarin Pharmaceutical Inc., San Rafael, CA). Finally, the “Control” group (n = 5) was patients with benign / mild hyperphenylalaninemia (PHE levels <600 µM with no diet or sapropterin therapy). After an overnight fast, preprandial and 1- and 2-hour postprandial samples were collected for each meal over 24 hours. Plasma was analyzed for amino acids and complete food records were analyzed. The maximum, mean, and standard deviation of PHE levels were calculated. Significance was calculated by two-way single factor ANOVA with post hoc Man-Whitney U test. The mean PHE levels were 1077, 306, 377, and 370 µM in the High PHE, Target PHE, Sapropterin, and Control groups, respectively. The High PHE group was significantly higher versus the other 3 groups (P < .0001), with the same pattern seen for the maximum PHE. The standard deviation of PHE was not significantly different between the groups. Intact protein intake was significantly lower in the High PHE and Target PHE groups compared to Control (P < .0001), while Sapropterin was not significantly different from Control. The most common diurnal PHE pattern was a high level in the morning with a decrease over 12 hours followed by a rise over night. PHE and PHE/Tyrosine ratio usually fell post-prandially, especially if PHE-free formula was consumed, and generally no “spikes” in PHE were seen post-protein intake. In conclusion, intact protein intake was similar between Sapropterin and Control groups, indicating a more “natural” diet in the Sapropterin group. PHE levels tend to fall throughout the day when eating and rise when fasting, which is an important consideration for timing of monitoring samples.
251 - Amino Acid Level Correlations Between Tandem Mass Spectrometry and Ultra-Performance Liquid Chromatography and the Clinical Relevance for Phenylketonuria Management
Murray Potter1, Amy Pender1, Erica Langley2, and Michael Geraghty2
1Mcmaster Children’s Hospital, Hamilton, Canada
2Children’s Hospital of Eastern Ontario, Ottawa, Canada
Management of phenylketonuria (PKU) and other metabolic disorders includes repeated measurement of analytes in blood to monitor and adjust therapy. Plasma or serum are common sample types, but their collection generally requires trained personnel and often requires a patient to travel to a blood collection center or laboratory. Whole blood collected as dried blood spots (DBS) on filter paper are commonly used in newborn screening, but because collection requires very little training and shipping to a central laboratory is inexpensive, this sample type can also be used for home monitoring. In our PKU clinic, plasma samples for amino acids (phenylalanine, in particular) are routinely measured by ultra-performance liquid chromatography (UPLC). Other samples are collected at home as DBS and these are shipped to our regional newborn screening laboratory, which offers amino acid analysis of monitoring samples by tandem mass spectrometry (TMS). The different analytical methodologies may contribute to possible bias between plasma and DBS sample types. Monitoring serial analyte levels in one PKU patient may include both sample types, therefore it is important to know about any bias when comparing results. 450 venous samples were collected on 32 patients with PKU. Each sample was collected in a syringe which was used to spot whole blood onto filter paper and then fill heparinized tubes for plasma separation. DBS samples were analyzed by a Waters Acquity TMS using flow injection and stable isotope dilution quantitation of a limited number of amino acids. Plasma samples were analyzed using MassTrac Amino Acid Analysis on a Waters Acquity UPLC. 9 amino acids were measured by both methods (alanine, arginine, citrulline, glycine, methionine, ornithine, phenylalanine, tyrosine, valine), while “leucines” (combined measurement of isobaric leucine and isoleucine on TMS) was compared to the sum of leucine and isoleucine (individually measured by UPLC). Phenylalanine showed a high correlation (R2 = 0.96) but DBS values were 15% lower than plasma (slope 0.85). Arginine and ornithine had poor correlation (R2<0.20). Most other amino acids showed good correlation (R2 0.70-0.88) but DBS consistently showed lower levels than plasma (ranging from 55% to 16% lower). These results show that DBS amino acid measurement by TMS has a negative bias compared to plasma measurement by UPLC. Caution should be exercised when comparing serial phenylalanine measurements using different methodologies.
252 - Trends in Overweight and Obesity Among Adolescent Classical Phenylketonuria Patients Between 2007 and 2017
Pelin Teke Kisa1, Oguzhan Baserdem2, Engin Kose3, and Nur Arslan3
1Division of Pediatric Metabolism and Nutrition, Dokuz Eylul University Faculty of Medicine, İzmir, Turkey
2Department of Pediatrics, Dokuz Eylul University, İzmir, Turkey
3Division of Pediatric Metabolism and Nutrition, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
253 - DNAJC12 Deficiency: A Novel Treatable Cause of Hyperphenylalaninemia, Central Biogenic Amines Deficiency, Dystonia, and Intellectual Disability: The First Six Patients
Manuel Schiff1, Tobias Haack2, Thierry Vilboux3, Ben Pode-Shakked4, Beat Thöny5, Nan Shen6, Virginia Guarani7, Thomas Meissner8, Ertan Mayatepek8, Friedrich Karl Trefz6, Aurora Martinez9, Jean-François Benoist1, Gali Heimer4, May Christine Malicdan3, Bruria Ben-Zeev4, Nenad Blau6, Georg F. Hoffmann6, Holger Prokisch2, Thomas Opladen6, and Yair Anikster4
1Robert-Debré Univ. Hospital, Paris, France
2Institute of Human Genetics, München, Germany
3Nih, Bethesda, MD, USA
4Sheba Medical Center, Tel Aviv, Israel
5University of Zurich, Zurich, Switzerland
6University of Heidelberg, Heidelberg, Germany
7Harvard Medical School, Boston, MA, USA
8University of Dusseldorf, Dusseldorf, Germany
9University of Bergen, Bergen, Norway
254 - Mutations of Phenylalanine Hydroxylase Gene Detected in 536 Patients From Southeastern Part of Turkey
Sebile Kilavuz1, Gülay Ceylaner2, Fatma Derya Bulut1, Deniz Kor1, Berna Seker Yilmaz1, Atil Bisgin3, Burcu Ozturk Hismi4, Sibel Öz5, Gülşah Şeydaoğlu6, and Neslihan Mungan1
1Department of Pediatric Metabolism and Nutrition, Faculty of Medicine, Çukurova University, Adana, Turkey
2Intergen Genetic Laboratory, Ankara, Turkey
3Faculty of Medicine, Department of Medical Genetics, Cukurova University, Adana, Turkey
4Department of Pediatric Metabolism and Nutrition, Tepecik Education and Research Hospital, İzmir, Turkey
5Faculty of Medicine, Department of Pediatrics, Çukurova University, Adana, Turkey
6Faculty of Medicine, Department of Bioistatistics, Çukurova University, Adana, Turkey
255 - Evaluation of the Relation Between the Physical Activity Practice and the Body Fat Percentage in Phenylketonuria Adolescents
Giovanna Caliman Camatta1, Viviane de Cássia Kanufre1, Raíssa Viana de Melo Lima2, Marina Ribeiro Mendes2, Michelle Rosa Andrade Alves1, Rosângelis Del Lama Soares1, Rocksane de Carvalho Norton1, Marcos José Burle de Aguiar1, Valéria de Melo Rodrigues1, and Ana Lúcia Pimenta Starling1
1Center for Action and Research in Support Diagnostics (Nupad), Belo Horizonte, MG, Brazil
2Federal University of Minas Gerais (Ufmg), Belo Horizonte, MG, Brazil
256 - Pedagogue Attributions in the Care of Patients With Phenylketonuria
Raissa Hilda Celestina Azevedo, Cezar Antônio Abreu de Souza, Michelle Rosa Andrade Alves, Rosângelis Del Lama Soares, Viviane de Cássia Kanufre, Valéria de Melo Rodrigues, Keyla Christy Christine Mendes Sampaio Cunha, Rocksane de Carvalho Norton, Giovanna Caliman Camatta, Ana Lúcia Pimenta Starling, and Marcos José Burle de Aguiar
Center for Action and Research in Support Diagnostics (Nupad), Belo Horizonte, MG, Brazil
257 - Pregnancy in Women With Phenylketonuria in Minas Gerais, Brazil
Giovanna Caliman Camatta1, Cezar Antônio Abreu de Souza1, Michelle Rosa Andrade Alves1, Juliana Pinheiro de Souza2, Rosângelis Del Lama Soares1, Viviane de Cássia Kanufre1, Valéria de Melo Rodrigues1, Keyla Christy Christine Mendes Sampaio Cunha1, Rocksane de Carvalho Norton1, Ana Lúcia Pimenta Starling1, and Marcos José Burle de Aguiar1
1Center for Action and Research in Support Diagnostics (Nupad), Belo Horizonte, MG, Brazil
2Faculty of Medicine of The Federal University of Minas Gerais (Ufmg), Belo Horizonte, MG, Brazil
258 - Comparison Between Casein Glycomacropeptide (CGMP-20) and Free Synthetic Amino Acids (AA) After a Standardized Meal on Selected Biomarkers in Phenylketonuria (PKU) Patients
Kirsten Ahring1, Erik Jensen2, Allan Melgaard Lund3, Karen Broendum-Nielsen4, Thomas Jensen5, and Lisbeth Birk Moller1
1Kennedy Centre, Cph Uni Hospital, Glostrup, Denmark
2Arla Foods Ingredients, Aarhus, Denmark
3Genetic Clinic, Cph Univ Hospital, Copenhagen, Denmark
4The Kennedy Centre, Cph Univ Hospital, Glostrup, Denmark
5Department of Biomedicine, Aarhus University, Aarhus, Denmark
259 - Compliance in Children Aged 4-12 Years With Classical PKU, When Current Recommendations of Phenylalanine Levels are Reduced to Follow European Guidelines
Louise Mosebo and Kirsten Ahring
Kennedy Center, Jmc, Copenhagen University Hospital, Glostrup, Denmark
Ultimo April 2016, the patients received a newsletter that the recommendations for phenylalanine levels would be changed. In a patient meeting in June 2016, all patients were once more informed of the changes according to the European Guidelines. January 2017 the patients again received a letter explaining the limits. Furthermore, some patients were informed of the new guidelines on their yearly, or half-yearly follow up visits. During the period, the patients have had the possibility to contact the dietician for advice how to reduce the phenylalanine level. Among other age groups, children aged 4-12 are influenced by the changes. The previous Phenylalanine recommendations were as follows: 4-10 year = 120-400 µmol/L and 10-12 year = 120-600 µmol/L. The new Phenylalanine recommendations are: 4-12 year = 120-360 µmol/L. The purpose of this project was to investigate the impact on children aged 4-12 years, with classical PKU. We wanted to know whether compliance was influenced by the new recommendations.
260 - PKU Genotype in Argentinean Patients
Rosa Elizabeth Enacan1, Laura Prieto1, Mariana Nuñez Miñana2, Luis Fernandez3, María Gabriela Valle1, Mercedes Salerno2, Claudia Fraga1, Fernando Santos Simarro3, Pablo Lapunzina3, Norma Spécola2, and Ana Chiesa1
1Fundacion de Endocrinologia Infantil (Fei), Buenos Aires, Argentina
2Unidad de Metabolismo. Hospital de Niños de La Plata, La Plata, Argentina
3Instituto de Genética Médica Y Molecular (Ingemm), Hospital Universitario La Paz, Idipaz, Universida, Madrid, Spain
261 - Performance on a Neurogenesis Sensitive Pattern Separation Task Suggests Hippocampal Deficits in Adult Phenylketonuria (PKU) Patients
Denise Hofman1, Helen Brooker2, Clare Lawton1, Mick Henderson3, Robert Barski3, Reena Sharma4, Arief Gusnanto1, Keith Wesnes2, and Louise Dye1
1University of Leeds, Leeds, United Kingdom
2Wesnes Cognition Ltd, Streatley On Thames, United Kingdom
3St James’s University Hospital, Leeds, United Kingdom
4Salford Royal Foundation NHS Trust, Salford, United Kingdom
Cognitive deficits in frontal lobe-related (executive) functions in Phenylketonuria (PKU) have been well documented. However, despite studies in PKU mice revealing reduced hippocampal synaptic connectivity, and volumetric MRI studies showing hippocampal volume loss in PKU patients, we are not aware of any studies assessing aspects of cognition specifically relevant to hippocampal functioning in the condition. fMRI studies have identified increased dentate gyrus activity when subjects are required to discriminate very similar objects in an object pattern separation task (e.g. deciding whether or not a closely similar image is original image they saw). Studies using object pattern separation paradigms have demonstrated selective age-related declines in the ability to discriminate closely similar images. Such deficits have also been shown using this type of task in people with amnesic Mild Cognitive Impairment and mild Alzheimer’s Disease. Research suggests that there is a relationship between compromised neurogenesis in the hippocampus and decreased ability to make these difficult discriminations. This study aims to assess hippocampal function in adult PKU patients compared to healthy controls, using the CogTrackTM pattern separation task. To date, 36 subjects (n = 19 PKU patients (13 Female [Mean Age 29.31 [SD:9.2], 6 Male [Mean Age 38.33 [SD:9.7] n = 17 healthy controls (11 Female [Mean Age 34.09 [SD:8.7], 6 Male [Mean Age 30.17 [SD:8.9]), have participated in an online study. Subjects were asked to complete a cognitive test battery on two occasions. The task reported here required subjects to distinguish closely similar images (neurogenesis sensitive stimuli) from previously presented images (original stimuli) following a 10-minute interval during which they engaged in other cognitive tasks. The pattern separation task accuracy scores were subject to a two factor Mixed Model Repeated Measures ANCOVA with age and gender as covariates. The analysis identified an interaction between the type of stimulus and the presence of PKU (P = .0195). The PKU patients were notably more impaired than controls in their ability to discriminate the closely similar pictures (the neurogenesis sensitive stimuli) than the original pictures. This suggests that cognitive functions which reflect hippocampal neurogenesis may be compromised in adult PKU patients. Data collection is ongoing.
262 - Estimation of Resource Use and Quality of Life in Phenylketonuria (PKU) Patients in Ireland
Gregory Pastores1, Jacqui Bracken1, Joanne Hughes2, Yvonne Rogers2, Celine Stenson2, Anne Clark2, Andrew Lloyd3, Ignacio Alvarez4, Mohit Jain5, Ashok Jha5, and Ardeshir Monavari2
1Mater Hospital, Dublin, Ireland
2Temple Street Children University Hospital, Dublin, Ireland
3Bladon Associates, Oxford, United Kingdom
4Biomarin Europe Ltd., Madrid, Spain
5Biomarin Europe Ltd., London, United Kingdom
263 - The perceived quality of life and the ability to cope with challenges in 73 adult phenylketonuric patients from newborn screening—The experience of a Portuguese center
Berta Alves1, Manuela Almeida2, Julio Rocha2, Ana Fortuna2, Carla Carmona2
1Fcnaup, Porto, Portugal
2Cent Gen Med, Chp., Porto, Portugal
264 - Potentials Effects of Phe Levels on the Cognitive Development, School Performance, Professional Career, and Socio-Affective Behavior of 73 Adult PKU Followed-Up by a Multidisciplinary Team at CGM-CHP
Carla Carmona, Manuela Almeida, Julio Rocha, and Ana Fortuna
Cent Gen Med, Chp., Porto, Portugal
265 - Can Other Genetic Diseases be Hidden Under Hyperphenylalaninemia? A Single Centre Experience
Graziella Cefalo1, Elisabetta Salvatici1, Marina Crosa1, Giovanna Sironi2, Ambra Maria Morgano1, Raed Selmi1, Sabrina Paci1, and Giuseppe Banderali1
1Department of Clinical Paediatric, San Paolo Hospital, University of Milan, Milano, Italy
2Department of Medical Genetics, San Paolo Hospital, University of Milan, Milano, Italy
We have evaluated among our patients affected by hyperphenylalaninemia the incidence of other genetic diseases. Out of a total of 630 patients affected by hyperphenylalaninemia, whose diagnosis was genetically confirmed, 250 are under diet therapy and 380 are not. Amongst the patients following dietetic therapy seven have been diagnosed with a second genetic disease: three are also affected by a different inherited metabolic disease (IMD) such as Short-Chain Acyl-CoA dehydrogenase (SCAD) deficiency, Medium-Chain Acyl-CoA dehydrogenase (MCAD) deficiency and cystinuria. One patient was found to have Moebius syndrome, another was diagnosed with pseudo-para-hypothyroidism. A genetic neuropathy Charcot-Marie-Tooth like was detected in an adult patient and a girl was diagnosed with chromosome 17 deletion (17.p.13.2). The second genetic disease was suspected and therefore investigated considering the presence of signs and symptoms not completely justified by hyperphenylalaninemia (neurological symptoms, mental delay, facial dysmorphisms, hypocalcemia and growth delay). A second genetic disease was discovered also in three of the 380 patients not following diet therapy. One child has been diagnosed with Noonan syndrome and another with the X-fragile syndrome. These two patients were investigated due to mental retardation and facial dysmorphism. A young woman also affected by congenital deafness was diagnosed with familial adenomatous polyposis. Out of a total of 630 patients affected by hyperphenylalaninemia 10 patients (1.6% of our population), up to now, have received a second diagnosis of genetic disease. It is therefore important when signs and symptoms not completely justified by a diagnosis of hyperphenylalaninemia are detected to continue the diagnostic process also with other genetic analysis. Our experience suggests that a first diagnosis of hyperphenylalaninemia does not exclude the possibility of a second genetic disease. Considering the possible phenotypical overlapping of different genetic disease, we should not settle for a single definite diagnosis particularly when we find ourselves in front of mental retardation or neurological symptoms of any severness.
266 - Analysis of the West of Scotland Maternal Phenylketonuria Clinic
Sarah Adam
Royal Hospital for Children, NHS Greater Glasgow And Clyde, Glasgow, United Kingdom
267 - Early Treated Phenylketonuria: DTI to Evaluate Microstructural Integrity of White Matter in a Spanish Pediatric Population
Maria Julieta Gonzalez1, Mónica Rebollo2, Pablo Ripolles Vidal2, Rosa Gassio1, Rafael Artuch3, Aida Ormazabal3, Cristina Sierra3, and Jaume Campistol1
1Neuropediatric Department, Pku Follow Up Unit, Institut de Recerca Pediàtrica H Sant Joan de Deu, Barcelona, Spain
2Neuroimaging Section, Neuropediatric Department, Institut de Recerca Pediàtrica, Barcelona, Spain
3Biochemical Department, Institut de Recerca Pediàtrica H Sant Joan de Deu, Barcelona, Spain
268 - New Tools to Investigate Phenylketonuria as a Perturbation of the Equilibrium Between Resting-State Phenylalanine Hydroxylase and an Architecturally Distinct Activated Phenylalanine Hydroxylase
Eileen Jaffe, Michael Hansen, Emily Arturo, and Elias Borne
Fox Chase Cancer Center, Tuhs, Philadelphia, PA, USA
Phenylalanine hydroxylase (PAH) exists as a slowly equilibrating mixture of an autoinhibited Resting-State structure and an architecturally distinct Activated structure; the relative population of these structures is governed by Phe binding allosterically to a site present only on Activated PAH. Phenylketonuria (PKU) can occur when the amount of Phe needed to favor accumulation of Activated PAH rises to neurotoxic levels. Because this “alternate-structures” description departs from the common view of PKU as a disorder of “protein folding”, it remains unknown how many disease-associated PAH variants adhere to this model. Nevertheless, our ultimate goal is to find pharmacological chaperones that can restore the intrinsic PAH tipping-point to safe Phe levels for common disease-associated variants. To this end, we have determined that a benign human PAH variant (C29 S) and the use of a cleaved His-SUMO tag facilitates investigation of human PAH structure and function. We report compounds that can potentiate the stabilization of Activated PAH by Phe. Excellent sensitivity was obtained screening potential candidate molecules using an enzyme kinetics approach in the normal physiological range of ∼100 µM Phe, rather than the less sensitive and saturating 1 mM Phe. PAH activation is complex and may reflect release of autoinhibition that is independent of the stabilization of the regulatory domain dimer now known to be specific to Activated PAH. Therefore, in addition to enzyme kinetic analysis, we monitored for the position of the PAH structural equilibrium using intrinsic protein fluorescence. The intrinsic fluorescence approach has been shown to provide a measure of the formation of the PAH regulatory domain dimer.
269 - 10 Year Retrospective Review (2003-2013) of 56 Inpatient Admissions to Stabilize Elevated Phenylalanine Levels
Anne Clark, Christine Merrigan, Aoife Coughlan, Ellen Crushell, Johanne Hughes, Ina Knerr, Eileen Tracey, and Ardeshir Monavari
National Centre For Inherited Metabolic Disorders, Dublin, Ireland
270 - Hyperphenylalaninemia Impairs Brain Energy Metabolism in Rats
Patricia Schuck1, Nádia Dimer1, Bruna Ferreira2, Jotele Agostini1, Maria Gomes1, Luiza Kist3, Fernanda Malgarin1, Milena Carvalho-Silva1, Lara Gomes1, Joyce Rebelo1, Marisa Frederico4, Fátima Silva5, Eduardo Rico1, Mauricio Bogo3, Gustavo Ferreira2, and Emilio Streck1
1Universidade do Extremo Sul Catarinense, Criciúma, SC, Brazil
2Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
3Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brazil
4Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
5Universidade Federal de Santa Catarina, Criciúma, SC, Brazil
Phenylketonuria (PKU) is a disorder of phenylalanine (Phe) metabolism caused by impaired phenylalanine hydroxylase activity, resulting in increased levels of Phe and its metabolites in fluids and tissues of patients. PKU patients present neurological signals and symptoms, such as hypomyelination and intellectual deficit. It has been shown that oxidative stress, calcium homeostasis and neurotransmitters metabolism are affected in PKU. The aim of this study was to analyze brain bioenergetics in the pathophysiology of hyperphenylalaninemia (HPA). For this study, 30-day-old Wistar rats were randomized into two groups. HPA group received a single subcutaneous administration of Phe (5.2 μmol/g) plus p-Cl-Phe (PAH inhibitor) (0.9 μmol/g). Control group received a single injection of NaCl 0.9%. One hour after injections animals were euthanatized and cerebral cortex, hippocampus and striatum were collected. The activities of lactate dehydrogenase (LDH), creatine kinase (CK), Krebs cycle enzymes and respiratory chain complexes were measured. It was also assayed concentrations of glycogen, free and total phosphate levels, as well as mRNA expression of PGC-1α, TFAM, NFR-1, SIRT3, SIRT5, MFN1, Polγ, and DRP-1. In cerebral cortex, HPA group showed decreased CK activity, glycogen levels, complex I-III and IV activities and CS activity, as well as increased LDH, α-KGDH and IDH activities, and the levels of free and total Pi. In striatum, HPA animals presented increased LDH and IDH activities, and decreased α-KGDH and complex IV activities. In hippocampus, HPA rats had increased α-KGDH and IDH activities, decreased complexes I and IV activities, and increased mRNA expression of MFN1. Our data demonstrated impaired bioenergetics in cerebral cortex, striatum and hippocampus of HPA rats. In conclusion, it may be speculated that disruption of brain bioenergetics is involved in neuropathology seen in PKU patients.
271 - Cutaneous Manifestations of Phenylketonuria in the 21st Century
Javier Dominguez-Cruz, Maria Bueno-Delgado, José Bernabeu, Carmen Delgado-Pecellin, and Julian Conejo-Mir
Universitary Hospital Virgen Del Rocio, Sevilla, Spain
272 - Brain-Derived Neurotrophic Factor and Platelet-Derived Growth Factors Levels Are Decreased in Plasma of Phenylketonuric Patients
Patricia Schuck1, Fernanda Malgarin1, Tassia Tonon2, Jotele Agostini1, Gustavo Ferreira3, Ida V D Schwartz4, and Emilio Streck1
1Universidade do Extremo Sul Catarinense, Criciúma, SC, Brazil
2Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
3Universidade Federal do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, RJ, Brazil
4Hospital de ClíNicas de Porto Alegre, Porto Alegre, RS, Brazil
Accumulation of phenylalanine (Phe) in tissue and body fluids of patients is the hallmark of phenylketonuria (PKU), an autosomal recessive disease. Brain injury is a clinical characteristic of PKU patients, although the pathophysiology of this damage is poorly understood. Therefore, the aim of this study was to evaluate the levels of neurodegeneration markers in plasma of PKU patients. Peripheral blood of 12 healthy individuals (control group) and 24 phenylketonuric patients were collected in heparinized tubes. Plasma Phe level was measured by high-pressure liquid chromatography. Quantification of plasma levels of brain-derived neurotrophic factor (BDNF), cathepsin D, neural cell adhesion molecule (NCAM), plasminogen activator inhibitor-1 (PAI-1), platelet-derived growth factor types AA, and AB/BB (PDGF-AA and PDGF-AB/BB), regulated upon activation normal T cells expressed and secreted (RANTES), intracellular adhesion molecule-1 (ICAM-1), and vascular cell adhesion molecule-1 (VCAM-1) was performed by ELISA method using commercial kits according to the manufacturers. It was observed that phenylketonuric patients presented a decrease in plasma levels of BDNF, involved in neuroplasticity and cell survival, PDGF-AA and PDGF-AB/BB, important molecules for oligodendrogenesis, when compared to control group. On the other hand, the levels of cathepsin D, NCAM, PAI-1, RANTES, ICAM-1, and VCAM-1 were not altered in plasma of phenylketonuric patients. Taken together, the present results suggest that the neurological damage and hypomyelination found in PKU patients might be related to impairment of neuron survival and plasticity and alterations in oligodendrogenesis, respectively.
273 - Epidemiological Clinical Profile of Patients With Phenylketonuria Treated at the Newborn Screening Service of Amazonas
Vania Prazeres, Flavia Tavares da Silva, Alcilante Queiroz Costa, Barbara Campos Perini, Bianka da Silva Paiva, Clarisse Diógenes Pinheiro Paiva, Fernanda Nakanishi Murakami, Juliana Veras de Mesquita, and Ricardo da Cunha Araújo
Secretaria de Saude do Amazonas, Manaus, AM, Brazil
274 - Comparison of Amino acid Autoanalyzer and Tandem Mass Spectrometry With Fluorometric Delfia Method for Phenylalanine Monitoring in PKU Patients
Gustavo Dratler, Hernán Eiroa, Romina Rodriguez, Silvia Marino, and Florencia Tommasi
Hospital de Pediatria Dr Jp Garrahan, Buenos Aires, Argentina
275 - Relationship Between Body Mass Index and Plasmatic Phenylalanine Concentration in Patients With Phenylketonuria
Carla Galbiati da Cruz, Marcela Lopes de Almeida, Nancy Yukie Yamamoto Tanaka, Elaine Hillesheim, Carla Barbosa Nonino, Marlene de Fátima Turcato, Marili André Coelho, Nattália Alves, Bárbara de Almeida Pinheiro, and Marina Estima Neiva Nunes
Fmrp/Hc-Usp Ribeirão Preto, Ribeirao Preto, SP, Brazil
276 - Behavioral and Emotional Problems in Brazilian Early-Treated Children and Adolescents With Phenylketonuria
Eduardo Vieira Neto1, Heber S. Maia Filho2, Claudia B. Monteiro3, Thuane Silva da Cruz1, Belisia Vasconcelos de Barros1, and Marcia Ribeiro1
1Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
2Departamento Materno-Infantil, Faculdade de Medicina, Universidade Federal Fluminense, Niterói, RJ, Brazil
3Núcleo de Estudos da Saúde do Adolescente, Nesa, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
277 - The Effect of Intact Protein from foods and Phenylalanine Free Medical foods on Large Neutral Amino Acids in Patients With Phenylketonuria
Ann Berry1, Teresa Douglas2, Anita Nucci1, and Rani Singh2
1Georgia State University, Atlanta, GA, USA
2Emory University, Decatur, IL, USA
278 - Blood Phenylalanine Reduction Corrects Monoamine Neurotransmitter Deficiencies and Improves Behavioral Performance but has no Effect Upon Cognitive Disability in Adult Mice With Phenylketonuria
Cary Harding1, Shelley Winn1, Tanja Scherer2, Beat Thöny2, Ming Ying3, Aurora Martinez3, Sydney Weber1, and Jacob Raber1
1Oregon Health & Science University, Portland, OR, USA
2University of Zurich, Zurich, Switzerland
3University of Bergen, Bergen, Norway
Central nervous system (CNS) deficiencies of the monoamine neurotransmitters dopamine and serotonin have been implicated in the pathophysiology of neuropsychiatric dysfunction in human phenylketonuria (PKU). In this study, we confirmed the occurrence of brain dopamine and serotonin deficiencies in association with severe behavioral alterations and cognitive impairments in hyperphenylalaninemic C57BL/6-Pahenu2/enu2 mice, a model of human PKU. Phenylalanine-reducing treatments, including either dietary phenylalanine restriction or liver-directed gene therapy, initiated during adulthood were associated with increased brain monoamine content along with improvements in nesting behavior but without a change in the severe cognitive impairments exhibited by these mice in the water maze. Following the behavioral and cognitive testing, the mice were euthanized for biochemical analyses. Brains of Pahenu2/enu2 brain showed significant reductions in the protein abundance and maximally stimulated activities of tyrosine hydroxylase (TH) and tryptophan hydroxylase (TPH), the rate limiting enzymes catalyzing dopamine and serotonin synthesis respectively, in comparison to those seen in wild type animals. Phenylalanine-reducing treatments initiated during adulthood did not affect brain TH or TPH content or maximal activity. Despite this apparent fixed deficit in striatal TH and TPH activities, initiation of phenylalanine-reducing treatments yielded substantial correction of brain monoamine neurotransmitter content suggesting that phenylalanine-mediated competitive inhibition of already constitutively reduced TH and TPH activities is the primary cause of brain monoamine deficiency in Pahenu2 mouse brain. We propose that CNS monoamine deficiency may be the cause of the reversible adverse behavioral effects associated with chronic hyperphenylalaninemia in Pahenu2 mice, although phenylalanine-reducing treatments initiated during adulthood are unable to correct the neuropathology and attendant cognitive deficits that develop during juvenile life in late-treated Pahenu2 mice.
279 - Treatment Decreases Homocysteine Levels in PKU Patients
Giovana Regina Weber Hoss1, Tassia Tonon1, Sidney Behringer2, Luciana Hannibal2, Henk Blom2, and Ida V D Schwartz1
1Ufrgs/Hcpa, Porto Alegre, RS, Brazil
2University Medical Center Freiburg, Freiburg, Germany
280 - Phenylketonuria: Nutritional survey with quantification of Phenylalanine intake in childhood: Assessing the need of nutritional guidance in patients with Hyperphenylalaninemia. Preliminary Report
María Gabriela Valle, Rosa Elizabeth Enacan, Claudia Fraga, and Ana Chiesa
Centro de Investigaciones Endocrinológicas “ Dr. Cesar Bergada” Cedie. Conicet-Hnrg-Fei, Buenos Aires, Argentina
Food habits differ worldwide from one culture to another. This is important when recommending a normal diet to patients with mild forms of metabolic disorders.
G) Phenylketonuria: Treatment, BH4 (281 to 301)
281 - Increasing the Dose of Tetrahydrobiopterin (BH4) Improves QOL of Patients With BH4-Responsive PKU
Haruo Shintaku1 and Toshihiro Ohura2
1Osaka City University Graduate School of Medicine, Osaka, Japan
2Sendai City Hospital, Sendai, Japan
282 - Outcomes of Pediatric Patients With Mild Hyperphenylalaninemia Who Were Diagnosed With Neonatal Screening Program
Nur Arslan, Pelin Teke Kisa, Gokberk Gurpinar, and Engin Kose
Dokuz Eylul University, Izmir, Turkey
283 - Improving PKU Management: Effect of Medical Education on Clinical Knowledge and Competence
Amy Larkin1, Stacey Hughes1, Karen Badal1, and Harvey Levy2
1Medscape Education, New York, NY, USA
2Boston Children’s Hospital, Boston, MA, USA
284 - DNA Damage Induced by Phenylalanine and its Metabolites: Effect of L-Carnitine
Marion Deon1, Tatiane Hammerschimitt1, Jessica Faverzani2, Camila Delgado2, Vanusa Manfredini3, Angela Sitta1, Daniella de Moura Coelho1, Moacir Wajner4, Roberto Giugliani1, and Carmen Regla Vargas1
1Medical Genetics Service, HCPA, Porto Alegre, RS, Brazil
2Grad Prog Pharmac Sciences, PPGCF, UFRGS, Porto Alegre, RS, Brazil
3Grad Prog Biochemistry, PPGBIOQ, Unipampa, Uruguaiana, RS, Brazil
4Grad Prog Biochemistry PPGBIOQ, UFRGS, Porto Alegre, RS, Brazil
285 - Phase 3 PRISM-2 Long-term Extension Study Evaluating Efficacy and Safety of Pegvaliase for Treatment of Adults with Phenylketonuria
Jerry Vockley1, Harvey Levy2, Stephen Amato3, Roberto Zori4, Janet Thomas5, Barbara Burton6, Cary O. Harding7, Nicola Longo8, John Posner9, Deborah Bilder8, Joy Olbertz10, Zonghua Gu10, Kelly Lau10, Mimi Lin10, Kevin Larimore10, and David Dimmock11
1University of Pittsburgh and Children’s Hospital of Pittsburgh, Pittsburgh, USA
2Boston Children’s Hospital, Boston, MA, USA
3University of Kentucky, Lexington, KY, USA
4University of Florida, Gainesville, FL, USA
5University of Colorado School of Medicine, Aurora, CO, USA
6Lurie Children’s Hospital of Chicago, Chicago, IL, USA
7Oregon Health and Science University, Portland, OR, USA
8University of Utah, Salt Lake City, UT, USA
9King’S College, London, United Kingdom
10Biomarin Pharmaceutical, Inc., Novato, CA, USA
11Rady Children’s Institute for Genomic Medicine, San Diego, CA, USA
286 - Biochemical and Genetic Investigation of Phenylketonuria Patients Treated With Sapropterin
Engin Kose1, Afig Berdeli2, and Nur Arslan1
1Division of Pediatric Metabolism and Nutrition, Dokuz Eylul University, Izmir, Turkey
2Ege University Pediatric Molecular Research Laboratory, Izmir, Turkey
287 - Bone Mineral Density and BH4 Treatment
Claudia Fraga, María Gabriela Valle, Rosa Elizabeth Enacan, and Ana Chiesa
Fundacion de Endocrinologia Infantil, Buenos Aires, Argentina
288 - Phase 2 Long-term Pegvaliase Treatment for Adults With Phenylketonuria: Updated Year 5 Safety and Efficacy Data from the PAL-003 Extension
Roberto Zori1, Harvey Levy2, Nicola Longo3, Kelly Lau4, Orli Rosen4, Mingjin Li4, Kevin Larimore4, Celeste Decker4, Haoling Weng4, and Jerry Vockley5
1University of Florida, Gainesville, FL, USA
2Boston Children’s Hospital, Boston, MA, USA
3University of Utah, Salt Lake City, UT, USA
4Biomarin Pharmaceutical Inc., Novato, CA, USA
5University of Pittsburgh and Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
289 - Dietary Treatment in Phenylketonuria (PKU): Only Benefits? Main Issues to Be Accounted
Sabrina Paci, Juri Zuvadelli, Valentina Rovelli, Graziella Cefalo, Elisabetta Salvatici, Alice Re Dionigi, Chiara Montanari, Raed Selmi, and Giuseppe Banderali
Pediatric Department, San Paolo Hospital, University of Milan, Asst Santi Paolo e Carlo, Milan, Italy
Patients with phenylketonuria (PKU) encompass an ‘at risk’ group for a wide range of imbalances, affecting not only nutritional issues but also other aspects, such as quality of life (QoL). We reviewed recent literature aiming to focus topics to always consider when dealing with PKU population. Micronutrient status: based on PKU dietary limitations, though supplements are commonly added to phenylalanine(Phe)-free mixtures, there’s still a risk of vitamin and mineral imbalances. This refers mainly to B12 vitamin, Se, Zn, Fe, folate, and ω3, with reference to age of treatment commencement, type of treatment, and dietary compliance. The need for supplementation in addition to what assured by mixtures is well established. Bone health: bone mineral density (BMD) has been widely used in scientific reports as main marker of bone status, being significant for Z-scores < or = −2 SD compared to general population (gp). Recent literature highlighted ↓ BMD in 90% PKUs but, deepening data, Z-scores were < −2.5 SD only in 5-14% PKU vs. 0.5% in gp. Further studies are needed to better establish fractures’ risk (lack of data in PKUs). Overweight and obesity: available data show PKUs BMI comparable to gp, though ↑ carbohydrates (CHO) dietary intakes are confirmed with consequences on daily glycemic index (GI) known to be correlated to non-communicable diseases (NCDs) in healthy adults. This highlights the need for GI to be primarily considered framing dietary intakes. Psychological issues: despite well-known sense of anxiety and guilt related to poor adherence to dietary treatment and pledge to maintain Phe levels within safe ranges, PKU QoL scores seems to be comparable to gp. Still, PKU patients tend to show ↑ vulnerability to psychiatric disorders than gp, with those showing better metabolic control being more diagnosed with such disorders, confirming the need of a psychologist/psychiatrist support. Our research confirms PKUs need to be strictly monitored throughout life achieving the best well-weighed nutritional intervention. A simple relationship between dietary intakes and nutritional status is not sufficient: many independent and interrelated complex factors should be evaluated other than quantitative issues. Much more is still needed to be done in order to guarantee the optimal equilibrium for each PKU patient considered in his entirety.
290 - Spanish Hyperphenylalaninemia Cases Bearing a Highly Frequent Mutation in the DNAJC12 gene
Fatima Leal1, Rosa Navarrete1, Margarita Castro1, Isidro Vitoria2, Maria Bueno-Delgado3, Amaya Belanger-Quintana4, Ana Morais5, Consuelo Pedron6, Concepción Garcia-Jimenez7, Valerie Hamilton8, Lourdes R. Desviat1, Magdalena Ugarte1, and Belen Pérez1
1Centro de Diagnóstico de Enfermedades Moleculares. Universidad Autonoma de Madrid, Madrid, Spain
2Hospital La Fe, Valencia, Spain
3H.U. Virgen Del Rocio, Sevilla, Spain
4H.U Ramón Y Cajal, Madrid, Spain
5H.U La Paz, Madrid, Spain
6H.U. Niño Jesus, Madrid, Spain
7H. U Miguel Servet, Zaragoza, Spain
8Inta, Santiago de Chile, Chile
Most cases with hyperphenylalaninemia (HPA) are caused by loss-of-function mutations in the PAH gene or by genetic defects in enzymes involved in the synthesis and regeneration of the PAH active cofactor tetrahydrobiopterin (BH4). In our lab, we have sequenced the PAH gene in more than 1036 cases after differential routine biochemical diagnosis to rule out a BH4 metabolism disorder. We sequenced the PAH gene by conventional Sanger sequencing combined with MLPA or in the last three years by massive parallel sequencing of the entire coding sequence in order to detect deep intronic mutations or genomic rearrangements. Biallelic or monoallelic pathogenic mutations were detected in 1021 cases. In this work, we report the genetic analysis of the recently described DNAJC12 gene in order to elucidate the molecular basis of 14 HPA cases from Spain and one from Chile with no mutations in the PAH gene. We have identified three novel nucleotide variations (c.524G>A, c.502+1G>C and c.298-2A>C) in 11 cases. All cases presented Phe levels at diagnosis >120 µM (120-337 µM), normal DHPR activity and normal urinary pterins levels. All cases are currently clinically asymptomatic but one presented psychomotor delay and seizures. Some cases presented Phe increase (400-500 µM) under febrile process. All are under normal diet and some of them are treated with BH4 with favorable response. The nucleotide change c.524G>A (p.Trp175Ter) was detected in 18 mutant alleles, eight homozygous and two heterozygous cases in combination with the splicing variations. All three variations were predicted to be pathogenic using the functional platform Alamut. The splicing variations were not detected in the worldwide population database ExAC while c.524G>A variation is present in EXAC and in a Spanish consortium database with a frequency less than 0.013% and 0.1%, respectively. These results suggest a likely frequent and founder mutation in our population that can be used as specific genetic marker. In summary, our DNAJC12 cases are in general clinically asymptomatic under normal diet although they should be included in follow-up in order to avoid in the future neurological symptoms related to neurotransmitter defects.
291 - Efficiency of Sapropterin Dihydrochloride in 112 Turkish Phenylketonuria Patients
Sebile Kilavuz1, Berna Seker Yilmaz1, Gülşah Şeydaoğlu2, Deniz Kor1, Fatma Derya Bulut1, Serdar Ceylaner3, and Neslihan Mungan1
1Department of Pediatric Metabolism and Nutrition, Faculty of Medicine, Çukurova University, Adana, Turkey
2Department of Biostatistics, Faculty of Medicine, Çukurova University, Adana, Turkey
3Intergen Genetic Laboratory, Ankara, Turkey
292 - Deficiencies of BH4 in Minas Gerais, Brazil
Cezar Antônio Abreu de Souza1, Michelle Rosa Andrade Alves1, Juliana Pinheiro Souza2, Rosângelis Del Lama Soares1, Viviane de Cássia Kanufre1, Valéria de Melo Rodrigues1, Keyla Christy Christine Mendes Sampaio Cunha1, Rocksane de Carvalho Norton1, Giovanna Caliman Camatta1, Ana Lúcia Pimenta Starling1, and Marcos José Burle de Aguiar1
1Center for Action and Research in Support Diagnostics (Nupad), Belo Horizonte, MG, Brazil
2Federal University of Minas Gerais (Ufmg), Belo Horizonte, MG, Brazil
293 - Deleterious Effects of Sepiapterin on Developing Reaggregated Rat Brain Cell Cultures
Noémie Remacle1, Mary Gonzalez-Melo1, Hong-Phuc Cudré-Cung1, Sonia do Vale Pereira1, Hugues Henry2, Ashley B Hale3, Keith M Channon3, Olivier Braissant4, and Diana Ballhausen1
1Center of Molecular Diseases, Lausanne University Hospital, Lausanne, Switzerland
2Biomedicine, Innovation & Development, Lausanne University Hospital, Lausanne, Switzerland
3Wellcome Trust Centre For Human Genetics, University of Oxford, Oxford, Great Britain
4Biomedicine, Lausanne University Hospital, Lausanne, Switzerland
294 - Challenges and Advances in Neurological Intervention for Control and Treatment of Phenylketonuria
Thiago Moreno1 and Andrea Arnholdt2
1Fmc, Campos dos Goytacazes, RJ, Brazil
2Uenf, Campos dos Goytacazes, RJ, Brazil
This work has the purpose to analyze the importance of the neurological intervention for control and treatment of phenylketonuria as a way to minimize this genetic disease of autosomal recessive inheritance, whose basic biochemical defect is the enzyme phenylalanine hydroxylase (PAH) deficiency, responsible for liver conversion of phenylalanine to tyrosine, and Intellectual disability is the most important sequel.
295 - Seventh Interim Analysis of the Kuvan® Adult Maternal Pediatric European Registry (KAMPER): Interim Results in BH4 Deficiency Patients
Francjan J. Van Spronsen1, Alberto Burlina2, Jan Alm3, Amaya Belanger-Quintana4, Francois Feillet5, Florian B. Lagler6, Ania C. Muntau7, Friedrich Trefz8, Elaina Jurecki9, Raivo Kittus10, and Ignacio Alvarez10
1Division of Metabolic Diseases, Beatrix Children’s Hospital, University Medical Center of Groningen, Groningen, the Netherlands
2University Hospital, Padova, Italy
3Karolinska University Hospital, Stockholm, Sweden
4Hospital Ramon Y Cajal, Madrid, Spain
5Hôpital D’Enfants Brabois, Vandoeuvre Les Nancy, France
6Paracelsus Medical University, Salzburg, Austria
7University Children’s Hospital, Medical Center Hamburg Eppendorf, Hamburg, Germany
8Division of Inborn Metabolic Diseases, University Children’s Hospital, Heidelberg, Germany
9Biomarin Pharmaceutical Inc., Novato, CA, USA
10Biomarin Pharmaceutical Inc., Europe, London, United Kingdom
296 - Seventh Interim Analysis of the Kuvan® Adult Maternal Pediatric European Registry (KAMPER): Interim Results in Phenylketonuria Patients
Francjan J. Van Spronsen1, Ania C. Muntau2, Florian B. Lagler3, Francois Feillet4, Jan Alm5, Alberto Burlina6, Amaya Belanger-Quintana7, Ignacio Alvarez8, Raivo Kittus8, Joshua Lilienstein9, Elaina Jurecki9, and Friedrich Trefz10
1Division of Metabolic Diseases, Beatrix Children’s Hospital, University Medical Center of Groningen, Groningen, the Netherlands
2University Children’s Hospital, Medical Center Hamburg Eppendorf, Hamburg, Germany
3Paracelsus Medical University, Salzburg, Austria
4Hôpital D’Enfants Brabois, Vandoeuvre Les Nancy, France
5Karolinska University Hospital, Stockholm, Sweden
6University Hospital, Padova, Italy
7Hospital Ramon Y Cajal, Madrid, Spain
8Biomarin Pharmaceutical Inc., Europe, London, United Kingdom
9Biomarin Pharmaceutical Inc., Novato, CA, USA
10Division of Inborn Metabolic Diseases, University Children’s Hospital, Heidelberg, Germany
297 - Interim Analysis of the Phenylketonuria (PKU) Patients Enrolled in the PKUDOS Registry
Joshua Lilienstein1, Barbara Burton2, Mitzie Grant3, Can Ficicioglu4, Jessica Kopesky5, Mina D. Nguyen-Driver6, Caroline Moore1, Elaina Jurecki1, and Nicola Longo7
1Biomarin Pharmaceutical Inc., Novato, CA, USA
2Lurie Children’s Hospital, Chicago, IL, USA
3St. Christopher’s Hospital for Children, Philadelphia, PA, USA
4Children’s Hospital of Philadelphia, Philadelphia, PA, USA
5Children’s Hospital of Wisconsin, Milwaukee, WI, USA
6Oregon Health And Science University, Portland, OR, USA
7University of Utah, Salt Lake City, UT, USA
298 - An Interim Analysis of the Kuvan® Adult Maternal Pediatric European Registry (KAMPER) and Phenylketonuria Developmental Outcomes and Safety (PKUDOS) Registries: Pregnancies
Francois Feillet1, Can Ficicioglu2, Florian B. Lagler3, Nicola Longo4, Jan Alm5, Ania C. Muntau6, Alberto Burlina7, Amaya Belanger-Quintana8, Friedrich K. Trefz9, Raivo Kittus10, Elaina Jurecki11, Ignacio Alvarez10, Joshua Lilienstein11, and Barbara Burton12
1Hôpital D’Enfants Brabois, Vandoeuvre Les Nancy, France
2Children's Hospital of Philadelphia, Philadelphia, USA
3Paracelsus Medical University, Salzburg, Austria
4University of Utah, Salt Lake City, UT, USA
5Karolinska University Hospital, Stockholm, Sweden
6University Children’s Hospital, Medical Center Hamburg Eppendorf, Hamburg, Germany
7University Hospital, Padova, Italy
8Hospital Ramon Y Cajal, Madrid, Spain
9Division of Inborn Metabolic Diseases, University Children’s Hospital, Heidelberg, Germany
10Biomarin Pharmaceutical Inc., Europe, London, United Kingdom
11Biomarin Pharmaceutical Inc., Novato, CA, USA
12Lurie Children’s Hospital, Chicago, IL, USA
299 - Discovery of Novel Compounds With Pharmacological Chaperone Potential for Therapeutic Correction of PKU
Aurora Martinez1, Jarl Underhaug1, Lars Skjærven1, Ming Ying1, Per M. Knappskog1, Seyed Mohammad Lellahi2, Gabriella Allegri3, Beat Thöny3, and Oscar Aubi1
1University of Bergen, Bergen, Norway
2University of Tromsø, Tromsø, Norway
3University of Zürich, Zürich, Switzerland
Phenylketonuria (PKU) is the most common inborn error of metabolism, caused by mutations in the gene encoding phenylalanine hydroxylase (PAH), resulting in increased phenylalanine levels in blood and toxic levels in brain. The current treatment consists of a strict phenylalanine-free diet from birth and supplementation with Kuvan®—a synthetic form of the cofactor tetrahydrobiopterin (BH4)—is also effective for some patients with milder phenotypes. But both treatments present pitfalls, including neurodevelopmental or psychosocial problems and low response-frequency among patients, respectively, and new therapeutic strategies are accordingly needed. One of the mechanisms of action of the cofactor is as a pharmacological chaperone, increasing the intracellular half-live of PKU-associated mutant PAH. We have performed a high-throughput screening protocol leading to the selection of 109 primary stabilizing compounds, which through validation of binding, activity assays and cellular studies were reduced to one final hit compound. This compound displayed good affinity (KD≈10 µM), enthalpically driven binding and excellent scores in cultured cells, with an increase of 50% activity for wild-type (WT) PAH, and up to 250% increase of activity and protein levels for recurrent PKU mutations such as p.I65 T and p. 261Q. Extensive derivatization of the compound has provided two series of compound analogues with increased affinity and improved potency in cells expressing PAH mutants, which are very effectively stabilized, reaching protein amounts and activity levels characteristic of the WT enzyme. These compounds exhibit a great pharmacological chaperone potential for the development of a novel treatment option for PKU.
300 - Experience With the Use of Tetrahydrobiopterin in the Medical Genetics Service of the Hospital de Clínicas de Porto Alegre
Tatiéle Nalin1, Tassia Tonon2, Luciana Giugliani3, and Ida V D Schwartz4
1Post-Graduation Program in Medicine: Medical Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
2Post-Graduation Program in Medicine: Medical Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, RN, Brazil
3Medical Genetics Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
4Department of Genetics, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
301 - One-year Follow-Up of B vitamin and Iron Status in Patients With Phenylketonuria Responsive and Nonresponsive to Sapropterin
Kristen Brantley1, Teresa Douglas2, and Rani Singh2
1Emory University, Atlanta, GA, USA
2Emory University, Decatur, IL, USA
H) Sulphur Amino Acid Disorders (302 to 318)
302 - Analysis of the Mutation Spectrum of the CBS Gene in Russian Patients With Classical Homocystinuria
Alla Semyachkina1, Elena Voskoboeva2, Ekaterina Nikolaeva1, and Elena Zakharova2
1Research and Clinical Institute of Pediatrics Named After Yuri Veltischev of The Pirogov University, Moscow, Russia
2Research Centre For Medical Genetics of The Russian Academy of Sciences, Moscow, Russia
The purpose of the study is to detect and analyze mutations in the CBS gene of classical homocystinuria in Russian patients.
303 - Chronic Mild Hyperhomocysteinemia alters Inflammatory and Antioxidant Parameters: Is Acetylsalicylic Acid a Neuroprotector?
Daniella de Souza Moreira, Paula Woltmann Figueiró, Helena Biasibetti-Brendler, Caroline Prezzi, and Angela Wyse
Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
Homocysteine is a sulfur-containing amino acid derived from the metabolism of methionine. When plasma homocysteine levels reach more than 10-15 µM, there is a condition known as hyperhomocysteinemia. It may occur as a result of an inborn error of methionine metabolism or by non-genetic causes. Hyperhomocysteinemia also is considered a risk factor for development of neurological and cardiovascular diseases. Our research group has developed a chronic chemically-induced model of mild hyperhomocysteinemia (up to 30 μM) in young adult rats and has shown its association with cerebral oxidative stress and inflammation. The objective of present study was to evaluate whether acetylsalicylic acid has neuroprotective effect on inflammatory parameters (acetylcholinesterase and interterleukin-1β) and antioxidant enzymes (catalase e superoxide dismutase) in rats subjected to mild hyperhomocysteinemia. Wistar male rats received homocysteine (0.03 μmol/g of body weight) by subcutaneous injections twice a day and acetylsalicylic acid (25 mg/kg of body weight) by intraperitoneal injections once a day from the 30th to the 60th postpartum day. Control rats received saline. Cerebral cortex was dissected for posterior biochemical analysis. Results showed that rats subjected to mild hyperhomocysteinemia increased acetylcholinesterase activity (P < .001) and interterleukin-1β levels (P < .05). Regarding antioxidant defenses, homocysteine increased catalase activity (P < .05) and decreased superoxide dismutase activity (P < .05). Acetylsalicylic acid per se did not alter these parameters, but prevented the increase of acetylcholinesterase and catalase activities. In summary, our findings showed that chronic chemically-induced model of mild hyperhomocysteinemia alters some inflammatory and antioxidant parameters and acetylsalicylic acid seems to have neuroprotective effect on some parameters that are associated to neurotoxicity of homocysteine. Supported by CNPq.
304 - Elevated Superoxide Levels, Mitochondrial Dysfunction, and Endoplasmic Reticulum-Mitochondria Crosstalk Disruption in ETHE1 and Sulfite Oxidase-Deficient Fibroblasts
Guilhian Leipnitz1, Bianca Seminotti2, Anuradha Karunanidhi2, Al-Walid Mohsen2, Johan Palmfeldt3, and Jerry Vockley2
1Ppg Ciências Biológicas Bioquímica, Depto de Bioquímica, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
2Division of Medical Genetics, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
3Research Unit for Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
ETHE1 and sulfite oxidase (SO) deficiencies are autosomal recessive disorders that affect the catabolic pathway of sulfur-containing amino acids. Both disorders are characterized by neurological symptoms that include seizures, hypotonia, and mental retardation, whereas ETHE1-deficient patients also present with chronic diarrhea, petechiae and orthostatic acrocyanosis. To better understand the pathophysiology underlying these symptoms, we investigated superoxide production, mitochondrial bioenergetics, and levels of endoplasmic reticulum (ER)-mitochondria crosstalk components in fibroblasts from patients. Primary human dermal fibroblasts obtained from 4 patients with ETHE1 deficiency and 1 patient with SO deficiency were cultured in media containing high glucose levels. We measured the levels of ETHE1 and SO proteins as well as of ER-mitochondria crosstalk components (IP3 R, Grp75 and VDAC1). Superoxide generation, mitochondrial membrane potential and mass, and ATP production were also determined. Our findings show absence or marked decrease of ETHE1 in ETHE1-deficient cell lines. Decreased SO content was observed in SO-deficient cells. We also verified decreased IP3 R and VDAC1 levels, and increased superoxide production in all ETHE1- and SO-deficient fibroblasts. While increased mitochondrial membrane potential and decreased ATP levels were observed in the SO-deficient cell line, no alterations of these parameters were found in ETHE1-deficient cells. Finally, mitochondrial mass was increased in two ETHE1-deficient cell lines. These data provide evidence that mitochondrial dysfunction generating high reactive oxygen species levels and ER-mitochondria crosstalk disruption are mechanisms involved in the pathophysiology of symptoms observed in ETHE1 and SO deficiencies.
305 - Natural History, Characterization, and Outcome of Classical Homocystinuria in the Qatari Population
Nader Aldewik1, Alaa Ali1, Noora Shahbeck1, Rehab Ali1, Laila Mahmoud1, Gheyath Nasrallah2, Johannes HaüBerle3, Beat Thöny3, Warren Kruger4, Henk Blom5, and Tawfeg Ben-Omran1
1Clinical and Metabolic Genetics, Department of Pediatrics, Hamad Medical Corporation, Doha, Qatar
2Department of Biomedical Sciences, College of Health Sciences, Qatar University, Doha, Qatar
3University Children’s Hospital and Children’s Research Center, Zurich, Switzerland
4Cancer Biology Program, Fox Chase Cancer Center, Philadelphia, PA, USA
5Laboratory of Clinical Biochemistry and Metabolism, Department of General Pediatrics, Adolescent Me, Freiburg, Germany
306 - Method Validation of Plasma Homocysteine by Cat-Ion Exchange Liquid Chromatography and its Comparison With a Chemiluminescence Immunoassay
Azeema Jamil, Aysha Habib Khan, Nasir Ali Khan, Hafsa Majid, and Lena Jafri
Aga Khan University Hospital, Karachi, Pakistan
307 - Biomarkers of Oxidative Stress, Inflammation, and Vascular Dysfunction in Inherited Cystathionine β-synthase Deficient Homocystinuria and the Impact of Taurine Treatment
Cynthia Freehauf1, Johan Van Hove1, Kenneth Maclean2, Can Ficicioglu3, Loren Del Mar Pena4, Hua Jiang1, Kerrie Moreau1, Patrick Henthorn1, Uwe Christians1, Sarah Young4, Michelle Hite5, Marisa Friederich1, Sally Stabler1, Elaine Spector1, Kathryn Kronquist1, Janet Thomas1, Peggy Emmett5, and Tina Cowan6
1University of Colorado, Aurora, CO, USA
2Univeristy of Colorado, Aurora, CO, USA
3Children’s Hospital Philadelphia, Philadelphia, PA, USA
4Duke University, Durham, NC, USA
5Children’s Hospital Colorado, Aurora, CO, USA
6Standfor University, Palo Alto, CA, USA
308 - Outcome of Late Detected Homocystinuria Due to CBS Deficiency in India
Anil Jalan1, Rishikesh Jalan1, Ketki Kudalkar1, Durga Shinde1, Monal Borugale1, Rasika Tawde1, Neelam Yadav1, Gauri Gaikwad1, Claudia Cozma2, Sabriana Eichler2, Susanne Zielke3, and Arndt Rolfs3
1Navi Mumbai Institute of Research In Mental And Neurological Hanidcap, Navi Mumbai, India
2Centogene Ag, Institute of Rare Diseases, Rostock, Germany
3Albrecht Kossel Institute, Medical Faculty, University of Rostock, Rostock, Germany
309 - In Vitro Evidence that Hydrogen Sulfide Disturbs Bioenergetics and Induces Mitochondrial Permeability Transition in Rat Brain
Leonardo de Moura Alvorcem1, Belisa Parmeggiani1, Nícolas Manzke Glänzel1, Renata Britto1, Pedro Fortes1, Cristiane Cecatto1, Alexandre Umpierrez Amaral1, Moacir Wajner2, and Guilhian Leipnitz2
1Ppg Ciências Biológicas, Bioquímica, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
2Ppg Ciências Biológicas, Bioquímica, Depto de Bioquímica, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
Ethylmalonic encephalopathy (EE) is a mitochondrial disorder caused by ETHE1 deficiency and biochemically characterized by hydrogen sulfide accumulation. Affected individuals have neurological dysfunction with cerebellum and basal ganglia abnormalities. We evaluated the in vitro effects of hydrogen sulfide (10-500 µM) on creatine kinase (CK) activity, mitochondrial respiration, membrane potential and swelling in brain of young rats. The effects of the free radical scavengers glutathione (GSH), melatonin (MEL), trolox (hydrosoluble analogue of vitamin E; TRO), and lipoic acid (LA) and of the xanthine oxidase inhibitor allopurinol (ALP) on CK activity were also examined. CK activity was measured in cerebellum and striatum supernatants. Mitochondrial respiration was assessed in cerebellum homogenates, whereas mitochondrial membrane potential (ΔΨm) and swelling were determined in cerebellum mitochondrial preparations. Our data demonstrated that hydrogen sulfide decreased CK activity in rat cerebellum and striatum, indicating that this metabolite disturbs energy transfer. Hydrogen sulfide-induced decrease of CK activity was prevented by GSH, MEL and TRO in cerebellum and striatum, while LA and ALP did not alter it. Furthermore, hydrogen sulfide decreased ADP- and CCCP-stimulated respiration, that represent oxidative phosphorylation and electron transfer system capacity, respectively, supported by complex I- and complex II-linked substrates in cerebellum. Hydrogen sulfide also decreased ΔΨm and induced swelling in the presence of calcium in cerebellum mitochondria. Decrease of ΔΨm was prevented by ruthenium red, while swelling was prevented by cyclosporine A and ADP, suggesting that hydrogen sulfide induces mitochondrial permeability transition (mPT) with the involvement of calcium. Taken together, our data indicate that impairment of energy transfer and production, and mPT induction may play an important role in the pathophysiology of cerebellum and basal ganglia damage observed in patients affected by EE.
310 - Disturbance of Redox Homeostasis by S-adenosylmethionine in Cerebral Cortex of Young Rats: Implications for the Pathophysiology of inherited Methylation Disorders
Ângela Zanatta, Cristiane Cecatto, Alexandre Umpierrez Amaral, Rafael Teixeira Ribeiro, Mariana de Oliveira Vargas Schimit, Guilhian Leipnitz, and Moacir Wajner
Departamento de Bioquímica, Icbs, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
Tissue accumulation of S-adenosylmethionine (AdoMet) occurs in various inherited methylation disorders, such as S-adenosylhomocysteine hydrolase (SAHH), glycine N-methyltransferase, and adenosine kinase deficiencies. Patients affected by these disorders usually have severe neurological features whose pathogenesis is practically unknown. We therefore investigated the effects of this metabolite on important parameters of cell redox status in cerebral cortex of young rats. Malondialdehyde (MDA) levels, carbonyl formation, 2′,7′- dichlorofluorescein (DCFH) oxidation, nitrate and nitrite levels, aconitase activity, glutathione (GSH) concentrations, and sulfhydryl content were determined. AdoMet markedly increased MDA levels and carbonyl formation, implying induction of lipid and protein oxidation, respectively. We also observed that AdoMet significantly increased DCFH oxidation but did not change nitrate and nitrite levels, indicating stimulation of reactive oxygen species generation. In contrast, this compound decreased GSH concentrations and sulfhydryl content, suggesting a decrease of antioxidant defenses. The activity of aconitase, which is highly vulnerable to oxidative attack, was also reduced by this metabolite. Furthermore, AdoMet-induced lipid peroxidation and GSH decrease were prevented by the antioxidants melatonin, alpha-tocopherol and resveratrol, indicating a role for reactive species in these effects. It is therefore presumed that disturbance of redox homeostasis by a major metabolite accumulating in SAHH and other methylation disorders may contribute to the pathogenesis of these diseases.
311 - Bezafibrate Pretreatment Prevents Glial Reactivity, Neuronal Damage, and Myelin Injury Induced by Sulfite Administration in Rat Striatum
Nícolas Manzke Glänzel1, Mateus Grings1, Belisa Parmeggiani1, Leonardo de Moura Alvorcem1, Mateus Struecker da Rosa1, Gabriela Miranda Fernandez Cardoso1, Gabriel Osorio Porto1, Angela Wyse2, Moacir Wajner2, and Guilhian Leipnitz2
1Ppg Ciências Biológicas, Bioquímica, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
2Ppg Ciências Biológicas, Bioquímica, Depto de Bioquímica, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
Sulfite oxidase (SO) deficiency is an autosomal recessive disorder which can arise either from the isolated deficiency of the enzyme SO or from defects in the biosynthetic pathway of its molybdenum cofactor. Patients present with severe seizures in infancy and progressive neurological damage, often resulting in early death, as well as tissue accumulation of sulfite. Since the pathomechanisms involved in the neuropathophysiology of SO deficiency are not fully understood, we determined the effects of sulfite administration on glial reactivity, neuronal damage, and myelin compaction and structure. We also evaluated the influence of a pre-treatment with the pan-PPAR agonist bezafibrate on sulfite-induced toxicity. Thirty-day-old rats were intrastriatally administered with sulfite (2 µmol) or NaCl (2 µmol; control) and euthanized 7 days after injection. Pre-treatment with bezafibrate (30 mg/kg/day) was performed by gavage during 7 days before sulfite administration. After euthanasia, striatum sections were used for immunohistochemical analysis. Sulfite administration increased S100B and GFAP staining in rat striatum, indicating that this metabolite induces glial reactivity. Furthermore, sulfite decreased NeuN and increased Fluro-Jade® C staining, suggesting neuronal damage. Bezafibrate pre-treatment prevented sulfite-induced increase of GFAP and decrease of NeuN. In addition, sulfite caused myelin injury, as reflected by decreased myelin basic protein (MBP) and FluoroMyelin staining, while bezafibrate prevented MBP decrease. Our data provide evidence that glial reactivity, neuronal damage, and myelin injury provoked by sulfite may underlie neurological symptoms and abnormalities found in SO deficiency. The fact that bezafibrate prevented sulfite-induced alterations also suggests that this protective compound may be a promising clinical candidate for SO-deficient patients.
312 - Rescue of CBS Mutants by Pyridoxine Administration: Demonstration of In Vivo Effect by Measuring Plasma CBS Activity
Viktor Kozich, Pavel Jesina, Jitka Sokolova, Jakub Krijt, Tomas Honzik, and Jiri Zeman
Institute of Iem, Charles Univ-1st Fac Med and General Univ Hosp, Prague 2, Czech Republic
313 - Sulfite Intrastriatal Administration Alters Signaling Pathways and Neuronal Injury Markers: Possible Mechanisms Involved in Sulfite Oxidase Deficiency Neuropathology
Mateus Grings1, Belisa Parmeggiani1, Renata Britto1, Pedro Fortes1, Angela Wyse2, Moacir Wajner2, and Guilhian Leipnitz2
1Ppg Ciências Biológicas, Bioquímica, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
2Ppg Ciências Biológicas, Bioquímica, Depto de Bioquímica, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
Sulfite oxidase (SO) deficiency is a recessive inborn error of metabolism biochemically characterized by high urinary excretion and tissue accumulation of sulfite. The main clinical and neuropathological findings include progressive encephalopathy, severe neonatal seizures, and basal ganglia abnormalities. Although the pathophysiology of neurological dysfunction in SO deficiency is not totally elucidated, sulfite accumulation has been suggested to play a major role. Therefore, we investigated the effect of sulfite intrastriatal administration on the content of proteins involved in key signaling pathways for cell survival and death (MAPK and Akt) and on neuronal injury (Tau protein, synapthophysin, and α-synuclein) and autophagy (LC3B) markers. Acridine orange staining was also used to evaluate autophagy. Thirty-day-old rats were instrastriatally injected with sulfite (2 μmol) or NaCl (2 μmol; control) and euthanized 30 min after injection. Striata were dissected and dissociated for acridine orange staining, or homogenized in RIPA buffer containing protease and phosphatase inhibitors to measure the immunocontent of proteins by western blotting. Our results showed that sulfite altered the content and phosphorylation of the MAPK ERK1/2 and p38 but not of JNK. Sulfite decreased ERK1/2 content, but increased its phosphorylation. On the other hand, sulfite decreased p38 phosphorylation without altering its protein content. Furthermore, sulfite increased Akt, synaptophysin and Tau protein content, whereas Tau phosphorylation was decreased. However, α-synuclein and LC3B content, and acridine orange staining were not altered by sulfite. Our findings suggest that alterations on MAPK and Akt signaling pathways caused by sulfite are possibly involved in neuronal injury observed in patients affected by SO deficiency.
314 - Erymethionase, Methioninase Entrapped in Red Blood Cells: An Innovative Treatment Approach for Classical Homocystinuria
Emmanuelle Dufour1, Aurelien Meyzaud2, Hyung-Ok Lee3, Sapna Gupta3, Francoise Horand2, Warren Kruger3, and Alexander Scheer2
1Erytech Pharma Inc., Cambridge, MA, USA
2Erytech Pharma, Lyon, France
3Fox Chase Cancer Center, Philadelphia, PA, USA
Classical Homocystinuria, resulting from cystathionine beta-synthase (CBS) deficiency, is recognized as the most common inborn error of sulfur amino acid metabolism. CBS metabolizes homocysteine into cystathionine, leading then to the synthesis of cysteine. Biochemical hallmarks of this disorder are elevated levels of homocysteine (Hcy) and methionine (Met). Patients symptoms include intellectual disabilities, thromboembolism, osteoporosis and ocular lens dislocation. Current treatments, for non-responsive Vitamin B6 patients, are methionine/protein restricted diets supplemented with betaine. However, adherence to this strict diet is not easy. As an alternative treatment approach to reduce the toxic accumulation of Hcy and Met we envisioned an innovative enzyme therapy. Erymethionase is a Methionine gamma-lyase (MGL from P. putida) entrapped in red blood cells using ERYTECH’s proprietary ERYCAPS technology platform to provide effective, long-acting therapeutic activity with reduced toxicity. MGL displays enzymatic activity with both Met and Hcy substrates with similar kms and a higher Vmax for Hcy (Ito et al, J Biochem vol 79, p 1263 and personal data). Reducing the level of both Hcy and Met is critical in restoring the metabolic balance in individuals with classical homocystinuria. Moreover, the red blood cell is the perfect transporter for PLP-dependent MGL enzyme as it provides the enzymatic cascade reaction to produce PLP from Pyridoxine (PN), molecule crossing easily the red cell membrane. PK, PD and safety parameters of Erymethionase were first evaluated in healthy mice. Once entrapped into erythrocytes, MGL maintained more than 30% of its specific activity after 5 days in circulation. In comparison, administration of the free form of MGL at similar doses led to a rapid loss of the enzymatic activity in few hours. The role of RBC in PLP biosynthesis from exogenous uptake of PN was also investigated in vivo. We are currently conducting experiments to demonstrate the potential of Erymethionase to lower plasma Hcy and Met in homocystinuria mouse model (Gupta et al, FASEB J, vol 28, p781). Preliminary results show an abrupt decrease of plasma Hcy following Erymethionase administration (131 µM vs the pathophysiological values 326-371 µM), when PN administration alone did not cause any decrease of Hcy or Met plasma levels. Further investigations are undergoing to determine the potential of Erymethionase as a therapeutic option for homocystinuria patients.
315 - S-Adenosylhomocysteine Hydrolase Deficiency—Intrafamilial Variability of Intellectual Disability Among Four Siblings
Danijela Petkovic Ramadza1, Ana Bogdanic1, Marina Grubic1, Maja Sedmak1, Mario Cuk1, Vladimir Sarnavka1, Nina Barisic1, Ksenija Fumic2, and Ivo Baric1
1Department of Pediatrics, University Hospital Centre Zagreb, Zagreb, Croatia
2Department of Laboratory Diagnostics, University Hospital Centre Zagreb, Zagreb, Croatia
S-adenosylhomocysteine hydrolase (SAHH) deficiency is an inherited methionine cycle disorder with multisystem involvement. Disturbed methylation is presumed, but the pathogenesis is not completely understood. Until now, ten patients have been described. Most of them had psychomotor delay, hypotonia, muscle weakness and liver involvement, but clinical presentation is variable. Two siblings had very severe course and died in early infancy and one patient was asymptomatic at seven years. We report follow-up of a family with four siblings suffering from SAHH deficiency due to mutations c.336G>A; p.W112X and c.428A>G; and p.Y143C of AHCY gene. Three boys have been reported previously. This is the first report on the fourth sibling, a female. Proband was started on low methionine diet, phosphatidylcholine, creatine and N-acetylcysteine at the age of 13 months, second child at the age of 3.5 months and two youngest siblings have been treated since birth. All patients had psychomotor delay, myopathy and mild hepatopathy. The myopathy is most severe in the first child who was started on diet later than other siblings. All patients had permanently elevated CK (10-100xN), permanently elevated aminotransferases and coagulopathy. Three boys had behavioral problems, mainly due to ADHD. At the age of 16, 13.5, and 10.5 years they had mild intellectual disability and attended school with individualized education plan. Psychological testing showed better verbal comprehension and perceptive reasoning, while they achieved lower scores in working memory and processing speed tests. The girl had severe developmental and speech delay, autistic behavior with stereotyped movements and temper tantrums. She started to walk unassisted at the age of 4 years. At the age of 7.5 she had moderate to severe intellectual disability and completely undeveloped speech. Her brain MR was normal and there were no signs of other neurological disease. Although all four siblings with SAHH deficiency had otherwise similar clinical presentation, there is quite variability in cognitive outcome. It is unclear why female sibling in whom the treatment was started and maintained since birth has the worst outcome. No other contributive factors could be identified. There is a report on patient who underwent liver transplantation and short follow up showed better cognitive functioning. Future studies on brain involvement in SAHH deficiency are needed to yield optimal treatment strategy.
316 - Intraleukocitary Cystine Quantification: Reference Values for Colombian Population
Olga Echeverri1, Johana Guevara1, Fernando Aldana2, and Carlos Alméciga-Díaz1
1Institute for the Study of Inborn Errors of Metabolism. P.U.J., Bogota, Colombia
2Recordati Rare Diseases Colombia, Bogota, Colombia
317 - Inflammation in Classical Homocystinuria: Analysis of 20 Cytokines in Brazilian Patients
Soraia Poloni1, Tatiéle Nalin1, Marina Siebert1, Karina Colonetti1, Giovana Regina Weber Hoss1, Henk Blom2, and Ida V D Schwartz1
1Laboratory Brain, Hospital de Clínicas de Porto Alegre, Brazil., Porto Alegre, RS, Brazil
2Laboratory For Clinical Biochemistry And Metabolism, University Medical Center, Freiburg, Germany, Freiburg, Germany
Classical homocystinuria (HCU; CβS deficiency) is characterized by high levels of homocysteine and methionine and cysteine deficiency. Its main clinical signs include lens dislocation, thromboembolism, intellectual disability, psychiatric disorders and osteoporosis. Increased pro-inflammatory cytokines are believed to play a role in the etiology of many chronic diseases, but the role of inflammation in HCU is unclear. In a previous study of 16 cytokines in HCU patients from USA (Keating et al., 2011), increased pro-inflammatory cytokines were found in non-treated HCU patients, while treated patients had normal levels of most cytokines studied.
318 - Sulfite Oxidase Deficiency: New Mutation and Phenotypic Variability (Case Report)
Andréa Rios1, Emília Katiane Leão2, Paula Correa2, Diego Miguel2, João Carlos Basbosa3, and Gildásio Conceição2
1Uneb, Salvador, BA, Brazil
2Hupes, Salvador, BA, Brazil
3Uesb, Vitória da Conquista, BA, Brazil
Sulfite oxidase (SO) deficiency is a hereditary autosomal recessive metabolic disorder due to mutations in the SUOX gene, which encodes the sulfite oxidase enzyme responsible for catalyzing sulfite oxidation to sulfate, causing a plasma and urinary accumulation of S-sulfocysteine. Clinical manifestations begin early after birth and are characterized by refractory seizures, delayed neuropsychomotor development, facial dysmorphisms, and dislocation of the lens. The diagnosis is based on clinical suspicion, magnetic resonance imaging of the brain, urine sulfite test, enzymatic activity in cultured fibroblasts and mutation research on the SUOX gene.
I) Other Amino Acid Disorders (319 to 358)
319 - Successful Pregnancy in a Woman With Alcaptonuria Treated by Nitisinone
Natacha Sloboda, Claire Bansept, Arnaud Wiedemann, Chrystele Bonnemains, and François Feillet
Reference Center For Inborn Errors Of Metabolism, Children University Hospital Of Nancy, Nancy, France
Alkaptonuria (AKU) is caused by homogentisate 1,2-dioxygenase deficiency, an enzyme converting homogentisic acid (HGA) to maleylacetoacetic acid in the tyrosine degradation pathway inducing joints and cardiac progressive disease. Nitisinone (NTBC) is a reversible inhibitor of 4-hydroxyphenylpyruvate dioxygenase indicated in the treatment of hereditary tyrosinemia type 1. This drug has been recently used off-license for patients with AKU, resulting in a striking decrease in the urinary and serum HGA concentrations, while increasing serum tyrosine (TYR) concentration. We describe here the first off-licensed use of NTBC during a pregnancy in a patient with AKU who had no history of joint or cardiac complication. A 33 years old woman was diagnosed with AKU in infancy and exhibited only a moderate ochronosis. No significant joint space narrowing was observed at the coxo-femoral joint. The echocardiography was normal. She has been treated by low-dose of NTBC (0.2 mg/day) since February 2013 with a mildly protein restricted diet without amino acids substitutes or low protein foods. After 9 months, serum HGA concentration was decreased by 94% while serum TYR concentration increased form normal to 406 ± 83 µmol/L. Our patient became pregnant in April 2016 and to avoid any secondary increase of HGA excretion, she gives her consent to continue NTBC treatment. Considering the toxicity of high phenylalanine level in maternal phenylketonuria, and in order to reduce any potential risk for the fetus, we aimed at keeping a target concentration of TYR <400 µM/L during all pregnancy (364 ± 104 µmol/L). As urinary HGA excretion increased during pregnancy, NTBC the dosage was increased at 0.5 mg/day from November 2016 until delivery without increased of blood TYR levels. During pregnancy, a metabolic and nutritional monthly follow up was performed and zinc and cobalamin supplementation were prescribed. She delivered in January 2017, and her son was fully healthy. In conclusion, we successfully used NTBC treatment during the pregnancy of a woman with AKU, with continuous metabolic efficacy and without any side effect for the mother and her son.
320 - Clinical, Biochemical, Outcome, and Molecular Features of 8 Patients Affected of Non Ketotic Hyperglycinemia
Talieh Zaman1, Ali Rahmanifar2, and Shirin Moarefian2
1Clinical And Research Unit Lachine, Montreal, Canada
2Clinical & Research Unit of Iranian National Society, Tehran, Iran
321 - Abnormal Social Behavior in Mice With Tyrosinemia Type I is Associated With an Increase of Myelin in the Cerebral Cortex
Gordon Macgregor and Marissa Moore
University of Alabama in Huntsville, Huntsville, AL, USA
Tyrosinemia type I is caused by mutations in the fumarylacetoacetate hydrolase (FAH) gene, the template for the final enzyme in the tyrosine catabolism pathway. If left untreated this deficiency of functional FAH leads to a buildup of toxic metabolites that can cause liver disease, kidney dysfunction, and high mortality. The current treatment with the drug NTBC prevents the production of these metabolites and has consequently increased the survival rate in tyrosinemia type I children. As a result of this increased survival, long-term complications of tyrosinemia type I are now being observed, including slower learning, impaired cognition, and altered social behavior.
322 - Asparagine Synthetase Deficiency Detected by Whole Exome Sequencing: The First Description in Two Brazilians Siblings
Carlos Henrique Grangeiro, Jair Huber, and Lucia Martelli
Universidade de São Paulo, Ribeirão Preto, SP, Brazil
Deficiency of asparagine synthetase is a very rare AR neurometabolic disorder caused by homozygous or compound heterozygous mutation in the ASNS gene (7q21.3) that encodes an asparagine synthetase enzyme. Congenital microcephaly; progressive encephalopathy, resulting in severe intellectual disability; brain abnormalities, axial hypotonia; appendicular spasticity; intractable seizures and hyperekplexic activity characterize this newly inborn error of non-essential amino acid synthesis. Additional variable dysmorphic features include micrognathia, receding forehead and large ears. The aim of this report is a clinical and molecular description of two Brazilian children with ASNSD analyzed by whole exome sequencing. We describe two siblings of a healthy and unrelated couple. A 11-year-old-boy with spastic quadriplegia, congenital microcephaly, seizures, and profound developmental delay was referred to a Clinical Genetics Division of HCFMRP due to a history of sister who died at 7 years of age with the same clinical picture and after extensive investigation in their state of origin. He was born by cesarean section due to fetal distress. His birth weight was 3.2 kg, length 48 cm and OFC: 30 cm. Seizures, global delay, axial hypotonia, and hypertonic extremities marked his clinical evolution. Laboratory examinations were normal including metabolic screening (plasma amino acid and very long-chain fatty acids analysis, urine organic acids, and isoelectric focusing of transferrin), chromosomal analysis, and array-based comparative genomic hybridization. Magnetic Resonance Imaging (MRI) showed microcephaly, Dandy Walker malformation, and cerebral and cerebellar global volumetric reduction. Exome sequencing (Illumina HiSeq®) showed a compound heterozygous mutation in ASNS gene (c.893 T>G, p.Asp295Asn and c.1213 T>C, p. Ala405Thr) and both were predicted to be pathogenic by bioinformatics analyses. This is the first description of ASNSD in Latin America and the second in Western countries. Despite the impossibility of carrying out confirmatory molecular examination in the proband’s sister, there are sufficient clinical data that support these siblings represents about twenty patients around world. Whole exome sequencing has allowed the diagnosis of extremely rare diseases that are heterogeneous and/or overlap with other conditions. This report expanded the mutational spectrum of ASNSD and allowed the end of a painful diagnostic odyssey.
323 - Melatonin Supplementation as Preventive Therapy to Neurological Damage Caused by the Induction of Hypermethioninemia in Wistar Rats Offspring
Paula Woltmann Figueiró, Daniella de Souza Moreira, Cassiana Siebert, Caroline Acauan Prezzi, Angela Wyse
Ufrgs, Porto Alegre, RS, Brazil
Hypermethioninemia is an inborn error of methionine metabolism caused by deficiency of the S-adenosylmethionine enzyme, leading to an accumulation of this essential amino acid and its metabolites. Recent studies showed that pups of mothers submitted to gestational hypermethioninemia presented oxidative stress and inhibition of Na+K+-ATPase activity in encephalon. During fetal development, these changes could lead to memory deficit and/or development of neurodegenerative diseases in postnatal life. Melatonin is a hormone released by the pineal gland and is involved, among other functions, to circadian rhythm control, removal of reactive species, antiapoptotic effect and reduction of lipid peroxidation. The aim of this study was to verify the possible neuroprotective effect of melatonin on biochemical (Na+K+-ATPase) and behavior parameters (memory by water maze task) in hypermethioninemic rats offspring at 30-day-old. Methionine (2.68 μmol/g body weight) was administered subcutaneously in Wistar female rats, twice a day during entire pregnancy. Melatonin (10 mg/kg body weight) was administered at the same way, but once a day. Control rats were treated with saline or melatonin. Pups were submitted to Morris water maze task in order to verify spatial memory and 12 hours after the animals were killed by decapitation without anesthesia. Results showed that hypermethioninemia reduced Na+K+-ATPase (P < .05) activity and melatonin was able to significantly reverse such effect. Results also demonstrate that the pups treated with methionine presented memory deficit since the average learning time of these pups was longer when compared to the control group (P < .05). On the other hand, pups treated with melatonin obtained values closer to the control, but not significantly. In accordance with our studies, methionine inhibits Na+K+-ATPase activity, which is essential to brain function and changes in its activity could be, at least in part, one of the reasons memory deficit caused by gestational hypermethioninemia. Mechanisms of melatonin action must be further investigated to elucidate how it can work as a possible preventive therapy to reduce neurological disorders found in patients with hypermethioninemia. Supported by CNPq.
324 - Tyrosinemia type 1: A Treatable Cause of Hypertrophic Cardiomyopathy in Infancy
Sarar Mohamed, Amal Alhashem, and Aida Alaqeel
Prince Sultan Military Medical City, Riyadh, Saudi Arabia
325 - Clinical Spectrum of Alkaptonuria from a Country with High Consanguinity Rate: A Systematic Review
Yusra Hyder Zaidi, Hafsa Majid, Lena Jafri, Bushra Afroze, and Aysha Habib Khan
Aga Khan University Hospital, Karachi, Pakistan
326 - Characterization of a Series of Patients With Homocystinuria in the Western Center Region of Colombia
Gloria Liliana Porras Hurtado1, Carlos Andres Zapata Chica1, Diana Milena Belalcazar Cifuentes2, Henk Blom3, and Ida Vanessa D. Schwartz Schwartz4
1Comfamiliar Risaralda, Pereira, Colombia
2Metabolic Therapies, Pereira, Colombia
3Laboratory of Clinical Biochemistry and Metabolism, University Medical Centre Freiburg, Freiburg, Germany
4Medical Genetics Service/Hcpa, Genetics Department/Ufrgs, Brazil, Porto Alegre, RS, Brazil
327 - Inborn errors of metabolism: Anthropometric evaluation and body composition of a group of patients
Georgina Maria Zayas Torriente1, Yoandry Alfonso1, Díaz Fuentes1, Dainet Abreu Soto1, Juana Maggie Torriente Valle Torriente Valle1, Laritza Martínez-Rey2, Ursula Hilaria Carrillo Estrada3, and Adaljiza Torriente Fernández4
1Instituto Nacional de Higiene, Epidemiología Y Microbiologia, La Habana, Cuba
2Centro Nacional de Genética Médica, La Habana, Cuba
3Hospital Pediátrico Borras-Marfan, La Habana, Cuba
4Hospital Clínico Quir, Urgico Freyre de Andrade, La Habana, Cuba
Inborn errors of metabolism constitute a group of diseases in which the genetic alteration affects different metabolic pathways within the organism. They can be caused by deficiency of the enzymatic activity or by the failure in the mechanisms of transport of different compounds. In recent years, these diseases have been identified more frequently. Their knowledge allows to realize the diagnosis early and to establish the specific treatment to prevent the mental disabilities that they produce. Periodic anthropometric evaluation guarantees post-statural follow-up and adequate channeling during childhood and adolescence.
328 - Tyrosinemia Type I and Todan’s VI Cystic Duct: An Unexpected Association
Yamna Kriouile
Faculty of Medicine and Pharmacy of Rabat/ University Hospital Ibn Sina, Children’s Hospital In Rab, Rabat, Morocco
329 - Growth Patterns in the Irish Pyridoxine Non-responsive Homocystinuria Population and the Influence of Metabolic Control and Protein Intake
Orla Purcell1, Aoife Carey2, Tim Grant2, Jenny Mcnulty1, Anne Clark1, Deirdre Deverell3, Philip Mayne3, Joanne Hughes1, Ardeshir Monavari1, Ina Knerr1, and Ellen Crushell1
1National Centre For Inherited Metabolic Disorders, Temple Street Children’s University Hospital, Dublin, Ireland
2Department of Research, Temple Street Children’s University Hospital, Dublin, Ireland
3Department of Laboratory Medicine, Temple Street Children’s University Hospital, Dublin, Ireland
330 - Recommendations for Diagnosis and Treatment of Tyrosinemia Type I
Jeffrey Chinsky1, Rani Singh2, Can Ficicioglu3, Clara Van Karnebeek4, Markus Grompe5, Grant Mitchell6, Susan Waisbren7, Muge Gucsavas-Calikoglu8, Melissa Wasserstein9, Katie Coakley2, and C. Ronald Scott10
1Johns Hopkins University School of Medicine, Baltimore, MD, USA
2Emory University School of Medicine, Atlanta, GA, USA
3Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
4Bc Children’s Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
5Oregon Health and Science University, Portland, OR, USA
6Chu Sainte-Justine And Universite de Montreal, Montreal, Quebec, Canada
7Boston Children’s Hospital, Boston, MA, USA
8University of North Carolina, Chapel Hill, NC, USA
9The Children’s Hospital at Montefiore, New York City, NY, USA
10University of Washington School of Medicine, Seattle, WA, USA
Tyrosinemia type I (Hepatorenal Tyrosinemia, HT-1) is an autosomal recessive condition resulting in hepatic failure with comorbidities involving the renal and neurologic systems and long-term risks for hepatocellular carcinoma. An effective medical treatment with 2-[2-nitro-4-trifluoromethylbenzoyl]-1,3-cyclohexanedione (NTBC, nitisinone) exists but requires early identification of affected children for optimal long-term results. Initial efforts at newborn screening (NBS) to detect presymptomatic infants with HT-1 by measuring tyrosine levels identified some but not all HT-1 children. Recent methods using blood succinylacetone as the newborn screening marker is predicted to identify all infants affected with HT-1. If correctly identified and medically managed, the majority, if not all, of these infants can anticipate a life free of hepatic or renal disease. A satisfactory clinical management scheme is clearly needed for infants with HT-1 identified by newborn screening (NBS) or following presentation with clinical symptoms. To this end, a group of eleven clinical practitioners, including eight biochemical genetics physicians, two metabolic nutritionists, and clinical research psychologist, from the United States and Canada with experience in providing care for patients with HT-1 initiated a consensus-based process to establish uniform recommendations for identification and treatment of affected children. Using results from a systematic literature review, practitioner management survey, and a nominal group process involving two face-to-face meetings, recommendations were developed and are summarized in this presentation. Final recommendations were proposed if there was at least 80% agreement (strongly agree or agree). There was strong consensus in favor of newborn screening for HT-1 using blood succinylacetone as the primary marker, followed by diagnostic confirmation and early treatment with NTBC and diet. Consensus recommendations for both immediate and long term clinical follow-up of both positive newborn screened individuals and those identified through clinical symptomatic presentation are provided. In addition, organ specific complications and recommendations for follow-up and treatment will be discussed. Given the availability of sensitive newborn screening techniques and effective therapy, the outcomes for this multisystemic disorder should be dramatically improved with the use of more consistent approaches advocated in this presentation.
331 - Intermittent Maple Syrup Urine Disease (MSUD)—A Difficult Diagnosis
Mette Christensen, Morten Duno, Flemming Wibrand, and Allan Melgaard Lund
Department Of Clinical Genetics, Copenhagen University Hospital, Copenhagen, Denmark
Intermittent MSUD may be difficult to diagnose, due to absence of biochemical abnormalities between symptomatic episodes. Patients with intermittent MSUD have normal growth and development, but when ill, may present with severe neurological impairment. If not recognized and treated, the outcome may be fatal. We report here two Danish patients with intermittent MSUD, one with a fatal outcome.
332 - Biochemical Diagnosis of Nonketotic Hyperglycinemia in Cuba
Jiovanna Contreras-Roura, Ivette Camayd-Viera, Laritza Martínez-Rey, Aurelio David Padrón-Díaz, Alina Concepción Alvarez, Alexis Alles-Gustavo, and Lixandra Teixidor-Llópiz
National Center of Medical Genetics, La Habana, Cuba
Nonketotic hyperglycinemia is an inborn error of glycine metabolism, due to a deficit in the glycine cleavage system. The accumulation of glycine in tissues, blood, cerebrospinal fluid, and urine is a distinctive feature of this disorder. The seizures and central nervous system damage are the most important clinical symptoms. There are three variants: the classic form, the atypical variants and the transitory form. Biochemical diagnosis includes urine organic acid analysis and glycine quantification in plasma and CSF. In Cuba, there is not a neonatal screening program for identifying this disease, so the diagnosis we performed by clinical features. The aim of this work is to implement a protocol for the biochemical diagnosis of Nonketotic hyperglycinemia. A cross-sectional study was performed in 507 patients under clinical suspicion of aminoaciduria or organic aciduria in a period of three years (January,2014 -April,2017). In the patients with hyperglycinuria and a normal organic acids profile (GC-MS) we quantified glycine in blood and CSF by HPLC. Five patients with treatment for refractory seizures showed high glycine levels in urine and serum, and normal organic acid profiles. In all of them, the glycine CSF/plasma ratios were over than 0.08. Considering the clinical symptoms and the age of symptoms onset, the most common variants were neonatal classic and the infantile. A protocol for the biochemical diagnosis of Nonketotic hyperglycinemia in Cuba was implemented.
333 - Case Report of Treatment of Non-Ketotic Hyperglycinemia (NKH) With Amino Acid Based Glycine Free Powdered Infant Formula
Carlos Bolanos
Cenpi, Clinica Rosario Tesoro, Medellin, Colombia
334 - Acute and Long-Term Effects of Intracerebroventricular Administration of α-Ketoisocaproic Acid on Oxidative Stress Parameters
Emilio Streck1, Luciane Taschetto1, Giselli Scaini1, Hugo Zapelini1, Andrea Ramos1, Monique Michels1, Felipe Dal-Pizzol1, Patricia Schuck1, and Gustavo Ferreira2
1Universidade do Extremo Sul Catarinense, Criciúma, SC, Brazil
2Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
335 - Intracerebral Administration of Glycine Increases Blood-Brain Barrier Permeability and Induces Myelin Injury in Rat Brain
Belisa Parmeggiani1, Mateus Grings1, Gabriela Miranda Fernandez Cardoso1, Nícolas Manzke Glänzel1, Renata Britto1, Gabriel Porto1, Moacir Wajner2, and Guilhian Leipnitz2
1Ppg Ciências Biológicas, Bioquímica, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
2Ppg Ciências Biológicas, Bioquímica, Depto de Bioquímica, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
Non ketotic hyperglycinemia (NKH) is caused by defects in the glycine (GLY) cleavage system, leading to the accumulation of GLY in urine, plasma and cerebrospinal fluid (CSF) of patients. The most common presentation of this disorder is the neonatal form, that is characterized by lethargy, hypotonia, seizures, hiccups, and apnea appearing within the first week after birth. Common neuropathological findings include cortical atrophy, corpus callosum agenesis or dysgenesis and leukodystrophy. Although GLY accumulation has been implicated in the onset of the disease, its pathophysiology is not totally established. The objective of this study was to evaluate the effects of a single intracerebral injection of GLY (0.2 µmol/g) on blood-brain barrier (BBB) integrity and myelination in rat pups. On post-natal day (PN) 1, animals received either GLY or PBS (vehicle) into the ventricle. After reassuring the wellbeing of the pups, they were returned to their mother and kept under ideal conditions of temperature and light for two weeks. On PN 15, the rats were euthanized and samples were prepared to evaluate Evans Blue (EB) extravasation, and immunohistochemistry for myelin basic protein (MBP) and myelin-associated glycoprotein (MAG). Our results evidenced that GLY increased EB staining in brain, suggesting that GLY impairs BBB integrity. Regarding myelination, GLY decreased MBP and MAG staining in corpus callosum, and MBP in striatum. In contrast, no alterations on MBP and MAG staining were seen in cerebral cortex. Our data show that GLY increases blood-brain barrier permeability and induces myelin injury. It may be presumed that these pathomechanisms are involved, at least in part, in the neuropathology of NKH.
336 - Lack of Correlation Between Serum Ornithine Concentration and Chorioretinal Changes in Gyrate Atrophy Patients—One Center Experience
Karolina Stepien1, Kirti Jasani2, Andrew Hutchesson3, and Simon Kelly2
1Adult Inherited Metabolic Disorders, Salford Royal NHS Foundation Trust, Salford, Great Britain
2Ophthalmology Department, Royal Bolton Hospital, Bolton, United Kingdom
3Clinical Biochemistry Department, Royal Bolton Hospital, Bolton, United Kingdom
337 - Chronic Administration of L-Tyrosine Alters Oxidative Stress Parameters in Brain of Rats Supplemented With Omega-3 Fatty Acids
Milena Carvalho-Silva1, Lara Gomes1, Letícia Teixeira2, Joyce Rebelo1, Fernanda Malgarin1, Maria Gomes1, Bruna Ferreira1, Patricia Schuck1, Gustavo Ferreira3, and Emilio Streck1
1Universidade do Extremo Sul Catarinense, Criciúma, SC, Brazil
2Universidade do Extremo Sul Catarinense, Cricúma, SC, Brazil
3Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
338 - Effect of Acute and Chronic Administration of L-Tyrosine on Working Memory in Young Rats
Letícia Wessler, Milena Carvalho-Silva, Lara Gomes, Letícia Teixeira, Joyce Rebelo, Gislaine Réus, Airam Moura, Danyela Matos, João Quevedo, Patricia Schuck, and Emilio Streck
Universidade do Extremo Sul Catarinense, Criciúma, SC, Brazil
339 - Acute and Chronic L-Tyrosine Administration Increase Dopamine Levels in Rat Brain
Lara Gomes1, Milena Carvalho-Silva1, Letícia Teixeira1, Joyce Rebelo1, Carlos Blum-Silva2, Flávio Reginatto2, Patricia Schuck1, Gustavo Ferreira3, Emilio Streck1
1Universidade do Extremo Sul Catarinense, Criciúma, SC, Brazil
2Universidade Federal de Santa Catarina, Criciúma, SC, Brazil
3Universidade Federal do Rio de Janeiro, Criciúma, SC, Brazil
340 - Tyrosinemia Type I. How much NTBC is enough?
Aida Lemes1, María Machado1, Cristina Zabala2, Mariana Castro2, Betsy Segovia1, Laura Fernàndez2, Angela Cabrera2, and , Cecilia Queijo1
1Laboratorio de Pesquisa Neonatal, Crenadecer, Bps, Montevideo, Uruguay
2Unidad de Diagnostico Y Tratamiento, Crenadecer, Bps, Montevideo, Uruguay
Tyrosinemia type 1 (Tyr 1) is a rare autosomal recessive disorder of tyrosine metabolism with an incidence of 1:125,000 in Europe. The deficiency of the enzyme fumarylacetoacetase causes an accumulation of tyrosine and toxic metabolites. Mainly affects liver and kidney function. Diagnosis is based on the elevated levels of succinylacetone (SUAC) in urine and/or blood, which is pathognomonic. NTBC treatment is costly but lifesaving. It has to be combined with natural protein restriction supplemented with essential amino acids. NTBC dosage should be reduced to the minimal dose allowing metabolic control. Standard treatment is 1mg/k/d. Metabolic control is judged by SUAC normalization in blood or urine, plasma tyrosine <500 μM and NTBC levels in the therapeutic range 20–40 μM. Is our aim, to present a Tyr I case that archives metabolic control receiving half of standard doses of NTBC. Clinical case: 13 months of age male patient. Nonconsanguineous healthy parents. Normal growth and development. At 8 months of age pediatrician detected hepatosplenomegaly with hard liver on examination. High alpha-fetoprotein and coagulopathy. Ultrasound identified multiples nodules in the liver and normal kidneys. MRI: several cirrhotic nodules. Elevated blood and urinary succinylacetone confirmed diagnosis. NTBC was started on standard doses associated to diet at 11 months of age. Because economic issue during 16 days NTBC was changed to half of the doses and during 10 days, it was suspended. Urine and blood SUAC was not detected during this last 26 days. Blood NTBC was in therapeutic range during the period of half of doses and there was traces when he was 10 days without drug. Conclusions: Although the patient received half of standard doses of NTBC during a short period of time, the SUAC was not detected in blood neither in urine and blood drug remained in therapeutic range. We think our patient could be treated with this low doses and strict clinical and biochemical control is necessary for a long time. The achievement of therapeutic objectives with low doses is important in our developing country where it is difficult to access to high cost medication.
341 - The R588Q Mutation in SLC25A13 is a Common Cause of Citrin Deficiency in Pakistani Patients With a Highly Variable Phenotype in Children
Saikat Santra1, Julian Raiman1, Suresh Vijayaraghavan1, Srividya Sreekantam1, Mary Anne Preece1, Anita Macdonald1, Anne Daly1, and Clara Van Karnebeek2
1Birmingham Children’s Hospital, Birmingham, United Kingdom
2Academisch Medisch Centrum, Amsterdam, the Netherlands
342 - Non-Ketotic Hyperglycinemia in Twin Premature Infants: Novel Mutation in GLDC With two Phase Evolution
Emmanuel Scalais1, Celine Themelin1, Leon Bofferding1, Christine Geron1, Jean Bottu1, Linda de Meirleir1, Dina Amrom1, Frederic Mataigne1, Christine Verellen-Dumoulin2, Damien Lederer2, and Johan Van Hove3
1Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
2Institut de Pathologie Et Génétique, Gosselies, Belgium
3University of Colorado, School of Medicine, Aurora, CO, USA
343 - Late Diagnosis of Rare Type of Homocysteinuria and Treatment With Betaine (Cystadane): The First Experience in Russian Federation
Valentina Larionova1, Marina Bulatnikova2, Elena Koroleva3, Anastasia Vasilishina2, Elena Khramtsova1, Natalia Vokhmianina4, Sergey Dement5, and Irina Melnikova1
1North-Western State Medical University Named After I.I. Mechnikov, Saint-Petersburg, Russia
2Pokrovskii Bank of Stem Cells, Saint-Petersburg, Russia
3North-Western Center of Evidence Based Medicine, Saint-Petersburg, Russia
4Diagnostic Medical Center, Saint-Petersburg, Russia
5Academy of Molecular Medicine, Saint-Petersburg, Russia
Patient A, 2 3/12 year-old male, was diagnosed with homocysteinuria (defect of remethylation) at the age of 1 4/12 year, when complications of the disease occurred as partial atrophy of the optical nerves and blindness, breath difficulties, replacement hydrocephalus of atrophic type, severe delay of mental development. The patient was presented to a doctor at the age of 2 months with delay of growth of head circumflex noticed by the mother, microcephaly (circumflex of the head 38.5 sm), and diffuse muscle hypotonia. Ultrasonography revealed signs of severe diffuse abnormalities of brain structure in the form of mixed connected hydrocephalus of atrophic type, and retrocerebellum cyst. Antibodies to cytomegalovirus infection (CMV) class M were detected. Laryngomalation and micro aspiration syndrome were diagnosed. At the age of 4 months, ENMes showed signs of prior muscle leisure of upper and lower limb muscles. Metabolic myopathy was suggested. At the age of 7 months, MRI of the head showed picture of abnormal development of Denni-Yoker type, replacement hydrocephalus and hypoplasia of corpus callosum. Amino acid blood analysis revealed a decrease in the level of methionine, 5.52 mkM/L (N 6.00-110.00). Therefore, homocysteinuria was suspected. Severe hyperhomocysteinemia was found with total homocysteine level of 198.47 µmol/L (5.46-16.20 µmol/L). Vitamin B12 (419.85 nmol/L) and folic acid (24.35 nmol/L) indexes were normal. Methylmalonic aciduria was not detected. Cystadane 100 mg was prescribed of. Pathologic reactions were not noticed and the patient’s condition stabilized. Respiratory support lasted continuously for 7 months, was dismissed. The level total homocysteine decreased up to 77.1 µmol/L. Subsequent sequencing of the MTHFR gene by Sanger method showed mutations Ile256Phe and Pro348Ser.
344 - Patients Diagnosed With Hepatocellular Carcinoma With Tyrosinemia Type I
Havva Yazici1, Ebru Canda1, Esra Ben1, Sara Habif2, Ezgi Guler3, Sema Kalkan Uçar1, Funda Ozgenc4, Sema Aydogdu5, and Mahmut Çoker1
1Division of Pediatric Metabolism And Nutrition, Ege University Faculty of Medicine, Izmir, Turkey
2Division of Clinic Biochemistry, Ege University Faculty of Medicine, Izmir, Turkey
3Division of Radiology, Ege University Faculty of Medicine, Izmir, Turkey
4Division of Pediatric Gastroenterology, Ege University Faculty of Medicine, Izmir, Turkey
5Division of Pediatric Gastroenterology, Ege University Faculty of Medicine, Turkey, Turkey
The clinic symptoms of tyrosinemia type1 are numerous and can appear in any term extending from neonatal period to adulthood. Liver is the primary organ that is affected; kidney can also be influenced in the follow-up, there is a hepatocellular carcinoma (HCC) development risk. Four patients diagnosed with tyrosinemia type1 with HCC development were presented to draw attention to the association of these clinics.
345 - Nonketotic Hyperglycemia: Case Report
Juan Juarez-Rodriguez1, Manuel Silva-Cavazos1, Arturo Garza-Peña1, and Beatriz de La Fuente-Cortez2
1Zambrano-Hellion Hospital, San Pedro Garza Garcia, Mexico
2Department Of Genetics. Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
346 - L-carnitine Prevents Oxidative Stress in the Brains of Rats Subjected to a Chemically Induced Chronic Model of Maple Syrup Urine Disease
Caroline Paula Mescka1, Andrea Pereira Rosa2, Gabriel Henrique Schirmbeck2, Thales Hein da Rosa3, Felipe Catarino3, Laila Oliveira de Souza4, Gilian Guerreiro1, Angela Sitta5, Moacir Wajner5, Carmen Regla Vargas5, and Carlos Severo Dutra-Filho3
1Programa de Pós-Graduação Em Ciências Farmacêuticas, Ufrgs, Porto Alegre, RS, Brazil
2Programa de Pós-Graduação Em Ciências Biológicas: Bioquímica, Ufrgs, Porto Alegre, RS, Brazil
3Departamento de Bioquímica, Icbs, Ufrgs, Porto Alegre, RS, Brazil
4Programa de Pós Graduação Em Assistência Farmacêutica, Ufrgs, Porto Alegre, RS, Brazil
5Serviço de Genética Médica, Hcpa, Ufrgs, Porto Alegre, RS, Brazil
Maple syrup urine disease (MSUD) is an inborn error of metabolism associated with acute and chronic brain dysfunction that is caused by severe deficiency in the activity of the branched-chain α-keto acid dehydrogenase complex, enzyme involved in the branched-chain amino acid (BCAA) degradation pathway. Due to this blockage, high concentrations of the BCAAs as well as the respective keto acids accumulate in patients when on an unrestricted diet and during episodes of metabolic decompensation during intercurrent illness. The main symptomatology presented by MSUD patients includes ketoacidosis, failure to thrive, poor feeding, apnea, ataxia, seizures, coma, psychomotor delay and mental retardation, although, the neurological pathophysiologic mechanisms are poorly understood. It was recently reported that treated MSUD patients have L-carnitine deficiency (L-car), a compound with antioxidant properties that is used as adjuvant therapy in some inborn errors of metabolism. In the present study, it was investigated BCAAs effect on several oxidative stress parameters and evaluated the L-car efficacy against these possible pro-oxidant outcomes of a chronic MSUD model in the cerebral cortex and cerebellum of rats. The chemically chronic model of MSUD used in this study demonstrated that BCAAs induce lipid and protein oxidation (measured by thiobarbituric acid-reactive substances and protein carbonyl content, respectively), impaired brain antioxidant defenses (analyzed by reduced glutathione content and catalase, superoxide dismutase, glutathione peroxidase and glucose 6-phosphate dehydrogenase activities), and increase reactive species production (verified by 2′7′-dichlorofluorescein oxidation assay), particularly in the cerebral cortex. L-car treatment was able to prevent these effects, improving the activity of antioxidant enzymes, increasing the non-enzymatic antioxidant defenses, and diminishing the lipid and protein oxidative damage and reactive species production. Taken together, the present data indicate that chronic BCAA administration significantly increased oxidative stress in the brains of rats subjected to a chronic model of MSUD, and considering that the current treatment of MSUD involves a protein restricted diet, which is low in antioxidants and L-car, supplementation with this compound may be considered a suitable adjuvant therapy for MSUD patients because it can improve redox homeostasis in this disorder. Financial Support: CNPq, CAPES, FAPERGS, and FIPE-HCPA
347 - Nonketotic Hyperglycinemia: First Case of Patient With Biallelic Mutations in GCSH gene
Laura Arribas-Carreira, Rosa Navarrete, Irene Bravo-Alonso, Magdalena Ugarte, Belen Pérez, Celia Pérez-Cerdá, and Pilar Rodriguez-Pombo
Centro de Diagnóstico de Enfermedades Moleculares. Universidad Autonoma de Madrid. Ciberer, Madrid, Spain
The rapid analysis of genomic data is providing an effective tool in the diagnosis of Nonketotic Hyperglycinemia, a monogenic cause of neonatal epilepsy caused by a deficient activity of the glycine cleavage system (GCS), however the growing challenge is the correct interpretation of the clinical significance of identified variants. GCS consist of four different proteins, P-protein (GLDC), T-protein (AMT), L-protein and a small lipoylated H-protein (GCSH). Up to now, biallelic mutations in GCSH have not been identified. Here we present the genetic test and functional analysis of two novel variants identified in the GCSH gene of a patient who died at 18 days of age with a clinical and biochemical diagnosis of classic NKH. Massive-parallel exome sequencing using a customized gene panel designed to capture exome sequence of GLDC, AMT, DLD and GCSH genes identified the c.170A>G (p.His57Arg) and c.148-?_228+? del variants in the GCSH gene. Sanger sequencing of nucleotide variants in parent’s samples confirmed the Mendelian segregation. The scoring of pathogenicity of the missense change using several computational predictive programs returned a concordant result of pathogenic variants. To evaluate the functional effect of missense mutant protein we performed the ectopic expression of the mutant cDNA GCSH construct in a COS7 cell system, followed by enzymatic assay, western blot analysis to evaluate protein stability and immunofluorescence microscopy to evaluate subcellular location. The results rendered a mutant protein normal in quantity and size, properly located in the mitochondria and able to participate in the removal of CO2 from glycine. The nature of this functional test doesn’t discard an effect on total GCS activity, but our data point to p.His57Arg as a probably a hypomorphic variant which combined with the loss-of-function variant c.148-?_228+? del, could be responsible of the patient’s NKH phenotype. PI12/02078; PI16/00573; MINECO-FEDER. Fundación Isabel Gemio
348 - Ex Vivo Gene Therapy in a Pig Model of Hereditary Tyrosinemia Type 1: Spheroid Suspension Hepatocytes are a Valid Alternative to Single Cells for Intraportal Infusion
Clara Nicolas1, Raymond Hickey1, Kari Allen1, Zeji Du1, Rebekah Guthman1, Bruce Amiot1, Piero Rinaldo1, Aditya Bansal1, Mukesh Pandey1, Timothy Degrado1, Scott Nyberg1, and Joseph Lillegard2
1Mayo Clinic, Rochester, MN, USA
2Mayo Clinic, Children’s Hospitals of Minnesota, Rochester, MN, USA
We aimed to treat and cure a porcine model of hereditary tyrosinemia type 1(HT1) through ex vivo gene delivery via intraportal transplantation of single cell or spheroid suspension hepatocytes. We performed laparoscopic partial hepatectomies on six-week-old (15-20 kg) fumarylacetoacetate hydrolase (FAH)-deficient pigs (n = 6) and isolated hepatocytes ex vivo. Hepatocytes were transduced in suspension with a lentiviral vector expressing the FAH gene. Animals received autologous hepatocyte transplantation by percutaneous portal vein infusion of single cell (n = 3) or spheroid (n = 3) suspension. Portal pressures were measured during transplantation and ultrasound used to evaluate presence of thrombotic events. Engraftment and expansion of ex vivo corrected autologous hepatocytes were followed through biochemical/histological analysis and animals’ ability to thrive off protective drug NTBC. This experiment was repeated in two wild-type pigs and a cohort of wild-type mice: here, hepatocytes were labeled with Zirconium-89 to evaluate biodistribution through PET-CT. Animals receiving single cell suspension hepatocytes, 4.8-15.0 g, experienced a mean change in portal pressure of 0.8-6.0 mm Hg during injection. No thrombus was noted. Animals receiving spheroid suspension hepatocytes, 9.1-10.8 g, experienced a mean portal pressure change of 10.9-12.5 mm Hg. Portal vein thrombi were noted in two animals; portal infusions were stopped and enoxaparin administered for 7 days, at which time ultrasounds showed no thrombus. On PET-CT imaging post-operatively, no significant difference in biodistribution was found between single cell and spheroid hepatocytes in neither pigs nor mice. Liver biopsies at 6 months post-transplantation show presence of multiple FAH-positive nodules; biochemical analysis shows a trend towards normalization of tyrosine levels. All spheroid animals are clinically stable, with one animal currently gaining weight off NTBC treatment for over 6 months, suggesting effective treatment of the metabolic disorder. In this preclinical study, we show that ex vivo gene correction of autologous hepatocytes in FAH-deficient pigs can be performed using spheroid as well as single cell suspension hepatocytes, with single cell suspension allowing for infusion of larger numbers of hepatocytes but no significant difference in biodistribution. In addition, transplantation of larger spheroids presents a higher short-term risk for portal vein thrombosis and increased portal pressures.
349 - Ex Vivo Gene Therapy and Ectopic Hepatocyte Transplantation into Lymph Nodes for the Treatment of Hereditary Tyrosinemia Type 1 in a Large Animal Model
Clara Nicolas1, Raymond Hickey1, Kari Allen1, Zeji Du1, Rebekah Guthman1, Robert Kaiser1, Bruce Amiot1, Scott Nyberg1, Eric Lagasse2, and Joseph Lillegard3
1Mayo Clinic, Rochester, MN, USA
2University of Pittsburgh, Pittsburgh, PA, USA
3Mayo Clinic, Children’s Hospitals of Minnesota, Rochester, MN, USA
350 - Treatment of Hereditary Tyrosinemia Type 1 in a Large Animal Model Through In Vivo Lentiviral Gene Therapy
Clara Nicolas1, Raymond Hickey1, Kari Allen1, Zeji Du1, Rebekah Guthman1, Piero Rinaldo1, Robert Kaiser1, and Joseph Lillegard2
1Mayo Clinic, Rochester, MN, USA
2Mayo Clinic, Children’s Hospitals of Minnesota, Rochester, MNUSA
351 - Blood levels of Glutamine and Alanine are Signature Amino Acids for determining Aminoaciduria by Reverse Phase LCMS
Vanita Lal1 and Anand Das2
1AIIMS Jodhpur, Jodhpur, Rajasthan, India
2Global Fund, Dili, Timor
Blood levels of Glutamine and Alanine are Signature Amino Acids for determining Aminoaciduria. We analyzed 76 pediatric cases with different grades of encephalopathy without metabolic acidosis (Plasma Lactic acid was performed to rule out mitochondriopathies). Blood ammonia and lactic acid were analyzed in fresh plasma samples and the same was run on Reverse Phase HPLC (Agilent). High blood ammonia correlated well with high plasma levels of glutamine and alanine. Retention time(RT), the main determinant in amino acid peak identification for a particular amino acid can shift causing confusion as to what it signifies, RT is highly depended on temperature, pressure and humidity of the place of analysis. Retention time of that specific Amino acid can also overlap with artefacts or background noise giving false-positive results and hence misinterpretation. The high peak of glutamine and alanine can easily be identified and then could be further processed for specific amino acid in question. We conclude that LC-MS is the most sophisticated & robust investigative tool of non-volatile metabolites in diagnosing IEM viz alpha aminoacidopathies and aid in early diagnosis and the appropriate intervention.
352 - An Unusual Family Illustrating the Complexities of Enzyme and Molecular Analysis in Nonketotic Hyperglycinemia
Carol Hardy1, Adam Gerrard1, Piers Fulton1, Tim Hutchin1, Ann Bowron2, Anita Devlin2, Robert Mcfarland2, and Mary Anne Preece1
1Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, United Kingdom
2Royal Victoria Infirmary, Newcastle-Upon-Tyne, United Kingdom
Nonketotic hyperglycinemia (NKH) is a rare metabolic disorder with an estimated disease incidence of approximately 1/76 000 (Coughlin et al., 2017). NKH is attributable to defects of the glycine cleavage system (GCS). Approximately 80% of patients have biallelic mutations of the GLDC gene, encoding the GCS P protein, and ∼20% of patients have mutations of the AMT gene (T protein). A pair of siblings and their cousin presented as infants with increased glycine in blood (324 µmol/L, 340 µmol/L and 475 µmol/L respectively), CSF (55 µmol/L, 58 µmol/L and 72 µmol/L) and CSF: plasma glycine ratios (sibling 0.17, cousin 0.15) consistent with a diagnosis of NKH. GCS enzyme analysis of a liver biopsy from the proband showed normal activity excluding a P protein defect. Mutation analysis of the AMT gene identified two variants in the proband and her sibling, the previously reported c.664C>T p.(Arg222Cys) and a rare variant, c.-58C>T, of uncertain significance within the 5’UTR. Other rare variants in this region have been reported and suggest an important regulatory region of the AMT gene although this is not functionally proven (Coughlin et al., 2017). The cousin has the familial p.(Arg222Cys) variant and a different variant c.230C>T p.(Ser77Leu) in AMT, considered likely to be pathogenic. All variants were classified according to the American College of Medical Genetics guidelines for the interpretation of sequence variants (Richards et al., 2015). This rare family with three segregating AMT variants illustrates the complexities of enzyme and molecular analysis in NKH. Coughlin et al., Genet Med. 2017 19(1):104-111. Richards et al., Genet Med. 2015 17(5):405-24.
353 - Tyrosinemia Type III: Outcome in Two Siblings
Joana Correia1, Fabio Barroso1, Anabela Bandeira1, Laura Vilarinho2, Manuela Almeida1, Julio Rocha1, and Esmeralda Martins1
1Centro de Referência de Doenças Hereditárias do Metabolismo, Cmin-Chup, Porto, Portugal
2Unidade de Rastreio Neonatal, Metabolismo e Genética, Insa-Porto, Porto, Portugal
354 - BCAT2 Mutations cause a Novel Disorder of Hypervalinemia/Hyperleucine-Isoleucinemia, Autistic Features, and Developmental Delay Detectable by Expanded Newborn Screening
Ina Knerr1, Roberto Colombo2, Jill Urquhart3, Ana Morais4, Begona Merinero4, Simon Jones5, Yvonne Rogers6, Eileen Treacy6, Philip Mayne7, Giuseppe Zampino2, Sabrina Mackinnon8, Pilar Rodriquez-Pombo9, Wyatt Yue8, Simon Olpin10, and Siddharth Banka11
1Ncimd, Children’s University Hospital, Dublin, Ireland
2Agostino Gemelli University, Rome, Italy
3Manchester Center For Genomic Medicine, Manchester, United Kingdom
4Cedem Universidad Autonoma de Madrid, Madrid, Spain
5Manchester University Hospital, Manchester, United Kingdom
6Ncimd Children’s University Hospital, Dublin, Ireland
7Dep Pathology, Children’s University Hospital, Dublin, Ireland
8Nuffield Dep. Of Medicine, Univ. Oxford, Oxford, United Kingdom
9Cedem Universidad Autonoma de Madrid, Madrid, Spain
10Metabolic Biochem., Sheffield Children’s Hospital, Sheffield, United Kingdom
11Manchester Centre For Genomic Medicine, Manchester, United Kingdom
355 - Syndromic Progressive Infantile Neurodegeneration Caused by Novel Homozygous Variant in 3-hydroxyisobutyrl-CoA Hydrolase -First Case in Colombia
Estephania Candelo1, Lorena Diaz-Ordonez1, Léa Cochard2, Gabriela Caicedo-Herrera1, Ana Granados3, Juan Fernando Gomez3, and Harry Pachajoa4
1Ciacer, Universidad Icesi, Cali, Colombia
2Sciencespo University, Paris, France
3Fundación Valle Del Lili, Cali, Colombia
4Ciacer, Universidad Icesi And Fundación Valle Del Lili, Cali, Colombia
356 - Later Presentation and Management of Maple Syrup Urine Disease in an Infant With Developmental Delay and Failure to Thrive
Alessandra Braga, Nathalia Fernandes, Lilian Licurgo, Viviane Santos, Tamires Camargo, Julia Albuquerque, Luisa Simonsen, Monica Moretzsohn, and Hélio Rocha
Ippmg Ufrj, Rio de Janeiro, RJ, Brazil
Maple syrup urine disease is a rare autosomal recessive disorder caused by a deficiency in the activity of the branched-chain a-ketoacid dehydrogenase complex, being an inborn error of amino acid metabolism first described by Menkes in 1954. This rare disorder represents one of the causes of acute neonatal illness which results in disturbances of neurological development, such as seizures, lethargy and refusal of feeds, besides clinical significant fasting hypoglycemia, metabolic acidosis, and ketoaciduria, soon followed by hypertonicity, opisthotonus, and death if untreated. The abnormal odor of maple syrup is found in the urine, sweat and cerumen of most patients. The aim of the study was to evaluate the clinical course and alterations of marker metabolites since early diagnosis. Laboratory data as well as information on clinical course and the management were obtained retrospectively in medical record of the patient. The patient in this case report had a global development delay diagnosed since 2-years-old followed by hypotony and poor weight gain. Gas-chromatographic-mass spectroscopy of urine showed low rates of 2-hydroxisovaleric acid, 12-hydroxisocaproic and 2-hydroxi-3-metilvaluric. Plasma organic acids assay showed high titles of leucine, isoleucine and valine. Since that, the child was treated with thiamine, iron supplementation and dietary protein restriction and the intake of an iron fortified synthetic formula devoid of leucine, isoleucine and valine, with a remarkably improve on his development. A treatment protocol on maple syrup disease was designed to inhibit endogenous protein catabolism, sustain protein synthesis, prevent deficiencies of essential amino acids and maintain normal serum osmolarity, once persistent increases in the branched-chain amino acids, leucine, isoleucine and valine is observed, and frequently greater than 10-fold over normal. Treatment often requires a low branched-chain amino acid diet. The patients must be carefully followed by monitoring plasma amino acid concentrations repeatedly. Some patients respond to treatment with large doses of thiamine. Specific diagnosis by tandem mass spectrometry of this inherited disorder of amino acid metabolism mostly in newborns with seizures and other signs of acute severe metabolic decompensation aims to improve brain development and minimize severity.
357 - Alkaptonuria: Not and “Adult Disease” Anymore—Early Diagnosis for Treatment is Essential
Marina Estima Neiva Nunes, Juliana Pavesi, Rayana Maia, Thereza Cavalcanti, Marili André Coelho, Carla Andrea Cardoso Tanuri Caldas, Marcela Lopes de Almeida, Maria Avanise Yumi Minami, and Charles Lourenço
Usprp, Ribeirão Preto, SP, Brazil
358 - Methylamine Dynamics: Carnitine, Trimethylamine, and Trimethylamine Oxide
Carolina Galarreta, Sarah Choi, Jon Gangoiti, and Bruce Barshop
University of California, San Diego, La Jolla, CA, USA
Trimethylamine-N-oxide (TMAO), a carnitine metabolite produced from microbiome-derived trimethylamine (TMA), has been associated with cardiovascular risk, raising long-term safety concerns for carnitine supplementation in IEMs. We are studying dynamics of carnitine and its derivatives in patients with various IEMs receiving oral or intravenous carnitine. Methods: We measured plasma and urine carnitine, TMA, TMAO, betaine, dimethylglycine and N6-trimethyl-lysine. Fractional excretion (FE) was calculated from results in urine and plasma. We included 2 patients with medium-chain acyl-CoA dehydrogenase deficiency (MCADD), 3 with 3-methylcrotonyl-CoA carboxylase (3-MCC) deficiency, 3 with propionic acidemia (PA), and 1 respectively with ethylmalonic encephalopathy, isovaleric acidemia, glutaric acidemia type II (MADD), methylmalonic acidemia, primary carnitine deficiency (SLC22A5 mutation), beta ketothiolase deficiency, and trimethylhydroxy-lysine epsilon (TMHLE) dioxygenase deficiency. Results: Plasma or urine levels of carnitine or TMAO did not correlated simply with oral carnitine dose, implying multiple factors influencing their levels. Plasma TMAO correlated strongly (r = 0.92) with urine TMAO, but that wasn’t the case for carnitine (r = 0.27). Plasma and urine TMAO levels were very closely correlated; the FE was close to 1 for most patients. FE of creatinine was much lower for all patients, speaking for very efficient renal tubular carnitine reabsorption. Two patients had significantly higher carnitine FE: the patient with MADD and the patient with SLC22A5 deficiency. The explanation is obvious in the latter case of transporter deficiency, and the first case displayed renal tubular acidosis, likely due to mitochondrial dysfunction. The TMAO FE and carnitine FE were not correlated. Patients with PA had remarkably high levels of plasma TMAO. The ratio TMAO/(TMAO+TMA) was close to 1 for most patients except for the two patients receiving oral antibiotics. Plasma TMAO was significantly reduced (20-fold) in one patient with MCADD during IV carnitine infusion. Conclusions: We hypothesize that the TMAO renal reabsorption transporter system is not as efficient as the carnitine reabsorption system, even though it has been described recently that TMAO is reabsorbed by the same transporter (organic cation transporter 2). Antibiotic therapy affects the TMAO/TMA ratio likely due to microbiome disturbances. Patients with PA are at risk for high plasma TMAO levels.
J) Urea Cycle Disorders (359 to 383)
359 - The Diagnosis of Argininosuccinate Lyase Deficiency in a Screened Population
Francesca Moore
Human Genetics Society Of Australasia, Sydney, Australia
Argininosuccinate lyase deficiency is a urea cycle disorder which can present in the neonatal period with hyperammonemic encephalopathy, or later in childhood with episodic vomiting, growth and developmental delay. Diagnosis is made by detecting argininosuccinate in the plasma, CSF or urine samples of affected individuals. With the advent of expanded newborn screening, diagnosing presymptomatic infants has been possible through the measurement of citrulline in the dried blood spot sample. In New South Wales since the introduction of expanded newborn screening in 1998, 10 children have been diagnosed with this disorder. Seven, of these 10, had an increased citrulline on their newborn screening sample and three children, from two separate families, were diagnosed when investigated for other reasons. The oldest of these patients is now 17 years of age and this cohort of patients shows the spectrum of this disorder.
360 - First Report of Carglumic Acid in a Patient With Citrullinemia Type 1 (Argininosuccinate Synthetase Deficiency)
Engin Kose1, Pinar Kuyum2, Betul Aksoy2, Johannes HaüBerle3, Nur Arslan1, and Yesim Ozturk2
1Dokuz Eylul University Pediatric Metabolism, Izmir, Turkey
2Dokuz Eylul University Pediatric Gastroenterology, Izmir, Turkey
3Division of Metabolism, University Children’s Hospital Zurich and Children’s Research Center, Zurich, Switzerland
Carglumic acid is a structural analogue of human N-acetylglutamate, which can enter mitochondria to activate carbamoyl phosphate synthetase 1, hereby enhancing the activity of the urea cycle and promoting ureagenesis. In this report, we present a 6.5-year-old male patient with argininosuccinate synthetase deficiency who was successfully treated for 3.5 years with carglumic acid.
361 - Correction of Ureagenesis in OTC-Deficient spf-ash Mice Using Naked-DNA Minicircle-Vector Gene Transfer to Periportal Hepatocytes
Sereina Deplazes1, Hiu Man Grisch-Chan Hiu Man Grisch-Chan1, Andrea Schlegel2, Zhuolun Song2, Gabriella Allegri1, Nicole Rimann1, Tanja Scherer1, Ralph Fingerhut1, Johannes HaüBerle1, and Beat Thöny1
1University Children’s Hosptial Zurich, Zurich, Switzerland
2University Hosptial Zurich, Zurich, Switzerland
362 - Management of an Adult Patient With Late-Onset Ornithine Transcarbamylase Deficiency After Severe Adverse Reaction to Glycerol Phenylbutyrate
Alvaro Serrano Russi
Children’s Hospital Los Angeles, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
Patient JS was seen initially at 43 years of age after he presented with episodes of altered behavior, agitation and combativeness to a local emergency room. No significant childhood illnesses or protein aversion was reported. Initial ammonia was reported as 207 µM with a CPK of 409 UI/L, negative urine toxicology, normal liver function tests and normal imaging with no evidence of cirrhosis or portal hypertension. He had reported a prior history of anxiety and obsessive–compulsive disorder treated with desvenlafaxine and citalopram. There was no history of alcoholism. He was involved in power lifting for ten years prior to his admission and was intermittently using dietary supplements and testosterone boosters over the counter to become more competitive. On initial assessment at the clinic while asymptomatic, his plasma ammonia was 46 µM with a plasma citrulline of 16 µM (17-46 µM); arginine of 33 µM (32-120) and urine orotic acid of 0.6 mmol/mol/cr (0.4-1.2). Acylcarnitine profile and lactate were within normal limits. Sequencing for NAGS, CPS1 and OTC was completed. OTC sequencing showed a c.562G>C mutation at exon 6 (p.G188A). No mutation was detected in the other genes. He was started initially on sodium benzoate at 250 mg/kg/day and was readmitted due to lack of compliance, dietary indiscretion and continued involvement in intense physical activity at work and at the gymnasium. With addition of supplemental citrulline and increased compliance with protein restriction, he gradually decreased his levels of daily activity resulting in adequate control of his ammonia levels and decreased frequency of hospitalizations over time. After stable management for 6 months he was switched to glycerol phenylbutyrate but developed three weeks later a severe reaction consisting on angioneurotic edema requiring management for anaphylaxis including epinephrine and corticosteroids. No other potential allergens were detected. No allergy testing assay was available for glycerol or phenylbutyrate to directly confirm allergenicity. The adverse event was reported. Patient was switched back to sodium benzoate and has been kept on 20 grams a day of citrulline and sodium benzoate with no major adverse medical problems for the next 3 years. Levels of citrulline and arginine have been kept above control values and Benzoate levels have never been in the toxic range.
363 - Gene Therapy Corrects Hyperammonemia and Highlights Nitrosative Stress-Related Cerebral Disease in Argininosuccinate Lyase-Deficient Mice
Julien Baruteau1, Dany Perocheau2, Joanna Hanley1, Eridan Rocha-Ferreira2, Rajvinder Karda2, Joanne Ng2, Nattalie Suff2, Ahad Rahim3, Michael Hughes3, Blerida Banushi4, Helen Prunty5, Mariya Hristova2, Deborah Ridout1, Alex Virasami5, Simon Heales1, Steven Howe1, Suzy Buckley2, Philippa Mills1, Paul Gissen1, and Simon Waddington2
1Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
2Institute for Women’S Health, University College London, London, United Kingdom
3School of Pharmacy, University College London, London, United Kingdom
4Mrc Laboratory for Molecular Cell Biology, University College London, London, United Kingdom
5Great Ormond Street Hospital for Children Nhs Foundation Trust, London, United Kingdom
364 - Gyrate Atrophy With Hyperornithinemia: Report the First Case in Cuba
Jiovanna Contreras-Roura1, Ivette Camayd-Viera1, Jc González2, E Pérez2, Laritza Martínez-Rey1, Zoe Robaina-Jiménez1, and Aurelio David Padrón-Díaz1
1National Center Of Medical Genetics, La Habana, Cuba
2Ico Ramón Pando Ferrer, La Habana, Cuba
Gyrate atrophy of the choroid and retina (GACR) is an extremely rare inherited retinal dystrophy. The disease is an autosomic recessive disorder, caused by mutations in the ornithine aminotransferase gene (OAT), which is localized on chromosome 10q26. OAT gene mutations result in hyperornithinemia, typically with a 10- to 20-fold elevation of plasma ornithine levels. OAT deficiency causes hyperornithinemia, which results in progressive chorioretinal atrophy. Based on these observations, the aim of this work is to describe the diagnosis of a patient with gyrate atrophy of the choroid and retina through ophthalmological tests and quantification of ornithine in plasma by HPLC. This is the first report of GA in Cuba, diagnosed by ornithine levels in blood and the ophthalmologist assessment.
365 - Hyperphenylalaninemia in Argininosuccinic Aciduria: A Case Report
Incilay Lay1, Emine Goksoy2, Serap Sivri2, and Turgay Coşkun2
1Dept of Medical Biochemistry and Clinical Pathology Lab., Hacettepe University Faculty of Medicine, Ankara, Turkey
2Childrens Hospital Nutrition and Metabolism Unit, Hacettepe University Faculty of Medicine, Ankara, Turkey
Argininosuccinic aciduria (ASA) is an autosomal recessive disorder of the urea cycle, caused by argininosuccinate lyase (ASL) deficiency. ASA is characterized by life-threatening acute attacks with hyperammonemia. Therefore, hyperammonemia should be treated immediately. Herein, we present an 18-month-old male diagnosed with ASA, which was confirmed by biochemical and genetic analyses. This patient initially had normal blood phenylalanine, but due to resistant hyperammonemia, he had to receive long-term and high-dose intravenous infusion of sodium benzoate and sodium phenylbutyrate combination, which led to markedly increased blood phenylalanine levels (1440 µmol/L). The 18-month-old male was from consanguineous parents and diagnosed with ASL deficiency during the newborn period with p.R113 W (c.337C>T) homozygous mutation on ASL gene. He had several metabolic decompensation attacks despite protein restricted diet, oral sodium-benzoate and arginine treatment. In the last attack, he had persistent hyperammonemia, for which we had to administered intravenous sodium-benzoate and sodium phenylbutyrate combination drug infusion and oral phenylbutyrate. We detected high blood phenylalanine level with these drug therapies. There was also a septic infection caused by Escherichia coli and vegetation in right atrium which was diagnosed as endocarditis on echocardiography. After the infection was treated, drug therapies were gradually discontinued and a new diet with 0.35 g/kg natural protein was initiated, blood phenylalanine level returned to normal. It is known that phenylbutyrate is converted to phenylacetate in vivo. High phenylethylamine was detected in this patient’s urine, which suggested the presence of alkaline pH. We hypothesized that, in the presence of infection and alkaline medium in the blood, high blood phenylacetate may be decarboxylated to phenylalanine, causing an increase in blood phenylalanine levels.
366 - A Mild Intermittent Hyperammonemia Caused by a Novel Mutation in Ornithine Transcarbamylase Gene
Sarar Mohamed1 and Muddathir Hamad2
1Prince Sultan Military Medical City, Riyadh, Saudi Arabia
2King Saud University Medical City, Riyadh, Saudi Arabia
367 - Hepatic Organoids in a Urea Cycle Disorder, Citrullinemia
Soheil Akbari1, Gulben Gurhan2, Nevin Ersoy1, Onur Basak3, Berke Sengun2, Erkin Ozel2, Alper Bagriyanik1, Tamer T. Onder2, Nur Arslan1, and Esra Erdal1
1Izmir International Biomedicine and Genome Institute, Dokuz Eylul University, Izmir, Turkey
2Koc University, School of Medicine, Istanbul, Turkey
3Hubrecht Institute, Royal Netherlands Academy of Arts and Sciences, Utrecht, the Netherlands
In vitro three-dimensional (3D) organoid cultures hold great promise for modeling and cell-based therapies for a variety of complex, genetic, rare and degenerative diseases, some of which have no current treatments available. For liver diseases, such cell-based therapies are lacking and whole organ transplantation and surgical resection are still the major treatment options. This is partly because hepatocytes cannot be grown efficiently in cell culture. Here, we utilize human iPSCs-derived liver organoids for modeling Citrullinemia type I, an inherited urea cycle disorders of the liver which results from deficiency of the enzyme argininosuccinate synthase (ASS1), Dermal fibroblast was used to generate patient-specific human iPSCs via episomal reprogramming and differentiated toward mature hepatocytes under chemically defined conditions. Upon differentiation FACS-enriched progenitor cells were used to develop functional liver organoid cultures. The iPSCs-derived organoids from healthy donors and citrullinemia patients exhibited properties of mature hepatocyte functions such as LDL uptake, albumin secretion, cytochrome P450 metabolism, glycogen storage as well as marker gene expression. Organoids from citrullinemia-derived iPSCs exhibited phenotypes such as increased ammonia and citrulline accumulation, similar to the disease pathology observed in patients. These phenotypes could be rescued by ectopic expression of the wild-type ASS1 gene in patient derived organoids. Furthermore, organoids could be transplanted intrahepatically into immunocompromised mice and were able to integrate into the liver tissues. Thus, in this study, we report for the first time the generation of liver organoids from patient-specific human iPSCs for citrullinemia disease. These personalized iPSC derived-organoid cultures have the potential to be utilized in disease modeling, drug screening, personalized and regenerative medicine. This study was supported by TUBITAK projects with no: 115S465 and 213S182.
368 - Mutation Spectrum and Outcomes of 18 Patients With Citrullinemia Type I: A Single Center Experience From Argentina
Silene Silvera1, Celia Angaroni1, Johannes HaüBerle2, Raquel Dodelson de Kremer1, and Laura Laróvere1
1Cemeco, Universidad Nacional de Córdoba, Hospital de Niños, Córdoba, Argentina, Córdoba, Argentina
2Division of Metabolism and Children’s Research Center, University Children’s Hospital Zurich, Zürich, Zurich, Switzerland
369 - Ornithine Carbamyl Transferase Deficiency: Report of Two Cases
Yamna Kriouile
Faculty of Medicine and Pharmacy of Rabat/ University Hospital Ibn Sina, Children’s Hospital In Rab, Rabat, Morocco
370 - The States of Hyperammoniemia in Pediatrics: Lessons in 10 Years
Hamlaoui Mohamed1, Djadi Mohamed2, Berrah Hassina2, and Arrada Zakia2
1Pediatric Critical Care Chu H-Dey Algiers Algeria, Algiers, Algeria
2Pediatric Critical Care Chu Hussein Dey, Algiers, Algeria
In Algeria, screening for hereditary diseases of metabolism is not yet mandatory. Among these conditions, the states of hyperammonemia are at the origin of a high mortality because they are underdiagnosed because little known and therefore not sought after and therefore not treated.
371 - Clinical features, Biochemical profile, Neuroradiological Findings, and Treatment in Arginase Deficiency: A Single Center Experience
Nandaki Keshavan, Michelle Wood, Rachel Skeath, Mel Mcsweeney, Marjorie Dixon, Maureen Cleary, Lara Abulhoul, Emma Footitt, and Spyros Batzios
Department of Paediatric Metabolic Medicine, Great Ormond Street Hospital NHS Trust, London, United Kingdom
Arginase deficiency (AD) is a rare autosomal recessive urea cycle disorder (UCD), caused by mutations in the ARG1 gene encoding arginase which catalyzes the hydrolysis of arginine to ornithine and urea. Patients have hyperargininemia and progressive neurological impairment, but generally suffer fewer episodes of metabolic decompensation compared to other UCDs.
372 - Pathogenesis, Pathophysiology, and Treatment of Citrin Deficiency
Takeyori Saheki
Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
Citrin deficiency is now well known as a pan-ethnic disease, causing neonatal intrahepatic cholestasis (NICCD) in neonate, failure to thrive and dyslipidemia (FTTDCD) in infant, and adult-onset type II citrullinemia (CTLN2) in adult. Saheki et al described the enzymological properties of argininosuccinate synthetase (ASS) in the liver of the patients who suffered from citrullinemia and hyperammonemia, characterized by liver-specific decreases in ASS protein with no abnormality in ASS gene and named the disease adult-onset type II citrullinemia (CTLN2). Kobayashi et al [1] discovered the causative gene, SLC25A13, by homozygosity mapping and named the product of the gene citrin. We identified a number of mutations in SLC25A13 and showed a wide distribution and a high frequency of the mutations in East Asia including Japan, China, and Vietnam. We also showed that citrin is a liver-type mitochondrial aspartate glutamate carrier (AGC) [2]. Citrin deficiency patients suffer from not only CTLN2 but also many other diseases such as NICCD [3-5] and FTTDCD [6], and the other diseases such as hepatoma, pancreatitis and NASH. The diversity of the clinical states of citrin deficiency is derived from the function of citrin: Citrin as an AGC not only functions in supply of aspartate from mitochondria to cytosol, but also plays a role in transport of cytosolic NADH reducing equivalent from cytosol to mitochondria as a member of malate aspartate shuttle. Related to the functions of citrin, one of the most important characteristics of citrin deficiency is nutritional aspects showing carbohydrate toxicity; intake of carbohydrates deteriorates the patients by causing hyperammonemia. The carbohydrate toxicity was reproduced by an animal model, citrin/mitochondrial glycerol 3-phosphate dehydrogenase double-KO mice [7]. Using the citrin deficiency model mice, we showed the therapeutic effects of sodium pyruvate, protein, amino acid such and medium-chain triglyceride [8]. In the present talk, I will discuss therapeutic effects of amino acids in more detail analyzed with the model mice. [1] Kobayashi K et al. Nat Genet.1999;22;159, [2] Palmieri L et al. EMBO J. 2001;20:5060, [3] Tomomasa T et al. J Pediatr. 2001;138:741, [4] Tazawa Y et al. J 2001;138:735, [5] Ohura T. et al. Hum Genet. 2001;108:87, [6] Song YZ et al. Int J Mol Med. 2011;28:33, [7] Saheki T et al. J Biol Chem. 2007;282:25041, [8] Saheki T et al. Mol Genet Metab. 2012;107:322.
373 - Mitochondrial Carbonic Anhydrase VA Deficiency as the Cause of Neonatal Hyperammonemic Encephalopathy
Sílvia Sequeira1, Ana Teresa Pita2, Véronique Rüfenacht3, aJnd ohannes HaüBerle3
1Metabolic Unit, Hospital de Dona Estefânia, Chlc, Lisbon, Portugal
2Intensive Neonatal Unit, Hospital de Dona Estefânia, Chlc, Lisbon, Portugal
3Division of Metabolism and Children’s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
374 - Clinical-Molecular Features and Outcome of 20 Turkish Patients With Urea Cycle Disorders
Deniz Kor1, Berna Seker Yilmaz2, Fatma Derya Bulut2, Sebile Kilavuz2, Mehmet Satar3, Ozlem Herguner3, Burcu Ozturk Hismi4, Sinem Sari Gökay5, Özlem Tolu Kendir5, and Neslihan Mungan2
1Div Ped Metab Dis, Adana Numune Edu Res Hosp, Adana, Turkey
2Div Ped Metab Dis, Uni Cukurova, Adana, Turkey
3Div Ped Neonatol Dis, Uni Cukurova, Adana, Turkey
4Div Ped Metab Dis, Tepecik Tra Res Hosp, İzmir, Turkey
5Div Ped Emerg, Uni Cukurova, Adana, Turkey
375 - Automated urinary analysis by Nuclear Magnetic Resonance (NMR): Application of the Method to a Newborn With Hyperammonemia
Claire Cannet1, Lars Beedgen2, Friedrich Karl Trefz2, Juergen Guenther Okun2, Claus-Dieter Langhans2, Hartmut Schäfer1, Manfred Spraul1, Dorothea Haas2, Stefan Koelker2, and Georg F. Hoffmann2
1Bruker Biospin Gmbh, Rheinstetten, Germany
2Center for Metabolic Diseases Heidelberg, Metabolic Laboratory, Heidelberg, Germany
376 - In Vitro Studies in a Rat 3D Brain Cell Model Suggest Creatine as Treatment for Neurotoxicity in Argininosuccinate Lyase Deficiency
Carmen Diez-Fernandez1, Marc Loup2, Gaelle Diserens3, Jean-Marc Nuoffer4, Peter Vermathen3, Olivier Braissant2, and Johannes HaüBerle5
1University Children’s Hospital and Children’s Research Center, Zurich, Switzerland
2Inborn Errors of Metabolism, Biomedicine, Lausanne, Switzerland
3Departments of Radiology and Clinical Research, Bern, Switzerland
4Departments of Paediatrics and Clinical Chemistry, Bern, Switzerland
5University Children’s Hospital Zurich, Zurich, Switzerland
The urea cycle disorder (UCD) argininosuccinate lyase (ASL) deficiency (ASLD) is caused by a defective ASL enzyme (expressed in liver and brain). Patients exhibit a wide spectrum of phenotypes ranging from life-threatening neonatal hyperammonemia to no clinical symptoms but only elevated argininosuccinic acid (ASA) in body fluids. In contrast to other UCDs, even without hyperammonemia, ASLD patients often develop severe mental retardation and seizures. Our aim is to understand the impact on the developing brain of ASA and guanidinosuccinic acid (GSA), specific metabolites that accumulate in ASLD, and to test if creatine (Cr), decreased in ASLD, has beneficial effects. If confirmed, Cr could provide a novel co-therapy for ASLD, which would help prevent neurological damage. Primary rat brain cell 3D cultures were used to mimic ASLD by repeated addition of diverse combinations of ASA (0, 1, 10, 100 µM), ammonia (5 mM), Cr (1 mM) and GSA (0, 1, 10, 100 µM). Two time points were tested representing distinct developmental stages: from days in vitro (DIV) 5 to 13 (neonatal brain) and from DIV 14 to 22 (brain in maturation). After sample harvest and cryopreservation, metabolite measurements, immunohistochemistry, western-blotting and metabolomics were performed. A dose-dependent toxic effect for both ASA and GSA was observed; the astrocytes were the most affected cell type. Increasing ASA concentrations led to decreased expression of the astrocytic marker glial fibrillary acidic protein (GFAP) and to shorter astrocytic processes. At 100 µM ASA, swollen astrocytic cell bodies were observed. Ammonium exposure also led to shorter astrocytic processes and this effect could be reverted by addition of Cr. 100 µM GSA appeared toxic to developing brain cells, leading to a 150-fold increase in lactate dehydrogenase, which points out a drastic increase of cell death. Metabolomics showed separation between treatment groups and harvest dates, especially in presence of ammonia. Beside the well-known neurotoxic effect caused by ammonia, ASA and GSA also showed adverse effects in developing and mature brain cells. Co-treatment with Cr prevented some of the effects caused by ASA and ammonia in the 3D model used here. We therefore suggest further evaluation of Cr as co-therapy for ASLD to prevent neurological damage. Important for later use in humans, Cr is commercially available, and it is used as treatment for disorders in Cr synthesis with well-established doses in all age groups.
377 - A Genetically Engineered E. coli Nissle to Prevent Hyperammonemia in Urea Cycle Disorder (UCD)
Yves Millet, Jonathan Kotula, Kip West, Yangfeng Li, Mary Castillo, Paul Miller, Aoife Brennan, and Caroline Kurtz
Synlogic, Cambridge, MA, USA
Urea cycle disorders (UCDs) are a group of inherited diseases where the inability to efficiently convert waste nitrogen into urea leads to the toxic accumulation of systemic ammonia (NH3). The gut is known to be a major source of systemic NH3, thus capturing part of intestinal NH3 may mitigate disease symptoms. To carry out this therapeutic strategy, E. coli Nissle (EcN), a well-characterized probiotic, was engineered to convert NH3 to arginine (Arg) in the intestine by deleting a negative regulator of Arg biosynthesis and expressing a feedback-resistant Arg biosynthetic enzyme. In vitro data show that engineered strains, named SYNB1010 and SYNB1020 (SYNB), are able to consume NH3 and produce Arg at a rate of 2.4 and 0.65 μmol/109 cells/hour respectively. Pharmacokinetic studies done in mice dosed orally with 1010 SYNB cells, showed that ∼2.5% of bacteria survived transit through the GI tract, maintained their activity within the cecum and colon for 8 to 12 hours and gradually shed from the GI tract over 30 hours. qPCR studies of fecal shedding of SYNB strains in mice and the cynomolgus monkey showed no detectable sequences by 7 days following the last dose. Tracer studies using 15N-labeled Arg were conducted to determine the fate of the Arg produced by SYNB in vivo. 15N4-Arg spiked in mouse cecal content ex vivo was rapidly converted to 15N-labeled citrulline, ornithine and NH3, most likely by the combined activity of the microbiome arginases, arginine deaminases and ureases. In addition, 15N4-Arg introduced into the mouse colon by enema was almost entirely excreted in urine in the form of 15N1 and 15N2-labeled urea, in a 3:2 ratio. Together, those results suggest that the Arg produced by SYNB in the mouse GI tract may be metabolized in the intestine, absorbed and incorporated in the urea cycle in the form of intact Arg and its degradation products. The efficacy of SYNB in lowering NH3 was tested in spf-ash mice, a genetic model of UCD. In this model, SYNB was able to prevent systemic hyperammonemia caused by a high-protein diet. The safety of SYNB was tested in a 28-day non-GLP toxicology study in non-human primates and in a 28-day GLP toxicology study in mice. In both cases, no adverse test article-related effects were observed on animal health. The design of a phase 1 clinical trial evaluating the safety and tolerability of SYNB1020 following single and multiple doses in healthy volunteers, will be presented.
378 - OCT Deficiency in Females: 3 New Moroccan patients
Saloua Dahri1, Habiba Talbaoui1, Yamna Kriouile2, Céline Acquaviva3, Christine Saban3, and Layachi Chabraoui1
1Central Biochemistry Laboratory, University Hospital of Rabat, Rabat, Morocco
2Neuropediatric Unit Children Hospital of Rabat, Rabat, Morocco
3Laboratoire de Biochimie Maladies Métaboliques, Groupement Hospitalier Lyon-Est, Lyon, France
OTCD is the most frequent urea cycle disorder. It results from mutations in the OTC gene encoding a 354-residue polypeptide. The clinical picture in females is highly variable even within a family, depending on the X-inactivation pattern in liver. We present 3 girls, one aged of 2 years and two of 2 years and half who manifested recurrent vomiting, growth retardation, encephalopathic and psychotic episodes, and behavioral troubles. Investigations revealed hyperammonemia episodes, high plasma glutamine with decreased or normal citrulline and arginine. Elevated urinary orotic acid was the key parameter suggestive of ornithine trancarbamylase deficiency. DNA analysis (sequencing of all exons and adjacent intronic regions) in two patients revealed a heterozygous mutation respectively in the exon 3 (c.275G>A) and in the exon 4 (c.416T>G). The administration of a low protein diet, Sodium phenylacetate, sodium benzoate, and L. arginine led to rapid improvement of biological and clinical states. The mutations were explored by sequencing of the exon 3 and 4 of OTC gene in the parents and family members. No carrier was identified suggesting that the detected mutations could be neo-mutations.
379 - Clinical and Laboratory Characteristics of the Patients With Urea Cycle Disorders: 40 Years’ Experience of Hacettepe University
Ozlem Saritaş Nakip, Ayşegül Tokatli, Turgay Coskun, Serap Sivri, and Ali Dursun
Hacettepe University, Ankara, Turkey
This study aimed to evaluate the characteristics of urea cycle disorders in Turkey. We retrospectively investigated the patients with urea cycle disorders diagnosed and followed in our clinic from 1979 to 2016. Hyperammonemia due to other metabolic disorders and unconfirmed cases were excluded. Patients’ demographic characteristics, clinical and laboratory data at diagnosis, genetic investigation results, and current status of the patients were noted. Variance analysis, Mann-Whitney tests, and Kruskal-Wallis tests were used to compare between group variables. Pearson chi-square test was also used for correlation analysis. 85 patients and 129 hyperammonemic episodes were included. The most common type was citrullinemia type 1(51.8%) followed by ornithine transcarbamylase deficiency (24.7%). 42 of patients were confirmed by genetic analysis and 4 of mutations had not been reported so far. Of the 85 patients, 26 were lost to follow-up, 3 were followed by another center and 46,4% of the follow-ups were dead. Mean follow-up duration were 4.17 years (0 days-26.83 years). 30% of surviving patients had normal intelligence, while the rest were found to have developmental and mental retardation at various levels. There were no obvious triggers in most of the hyperammonemic crisis. 84.8% of the hyperammonemic episodes were recovered and the rest resulted with death. The initial and peak ammonia levels were associated the most with mortality and neurological outcome. We also found that the high ammonia levels were associated with hypocalcemia, hypernatremia and polycythemia. We also identified 4 new genetic changes that needs to be confirmed by functional analysis.
380 - Citrin Deficiency: Assessment of the Carrier Frequency and Identification a Novel Ashkenazi Jewish Founder Variant with Unique Clinical Phenotype for an Underdiagnosed Urea Cycle Disorder in the US
Kimihiko Oishi, Ashley H. Birch, Neal Cody, Ruth Kornreich, Lisa Edelmann, and George Diaz
Icahn School Of Medicine At Mount Sinai, New York, NY, USA
381 - Comprehensive Biochemical and In Vivo Flux Studies in the Spf-Ash Mouse, A Model for Human X-Linked OTC Deficiency
Gabriella Allegri, Sereina Deplazes, Hiu Man Grisch-Chan Hiu Man Grisch-Chan, Nicole Rimann, Tanja Scherer, Déborah Mathis, Ralph Fingerhut, Beat Thöny, and Johannes HäBerle
Kinderspital Zürich, Zürich, Switzerland
382 - Follow-up of the Two Cases With the Diagnosis of Neonatal Citrin Deficiency
Ebru Canda1, Havva Yazici1, Esra Ben1, Yasemin Atik Altinok1, Sara Habif2, Sema Kalkan Uçar1, Huseyin Onay3, Ferda Ozkinay3, and Mahmut Çoker1
1Pediatric Metabolism and Nutrition, Ege University Faculty of Medicine, Izmir, Turkey
2Department of Biochemistry, Ege University Faculty of Medicine, Izmir, Turkey
3Department Of Genetics, Ege University Faculty of Medicine Izmir, Turkey
Citrin deficiency is due to lack of function of the hepatic mitochondrial aspartate/glutamate transporter/carrier citrin which is caused by the mutation in SLC25A13 gene. There are two main age-dependent clinical presentation. We presented two cases with Neonatal Intrahepatic Cholestasis Caused by Citrin Deficiency (NICDD). A 5-month-old girl referred to our clinic due to cholestasis, urinary reductant positivity, elevated blood total galactose and free galactose. On her physical examination hepatosplenomegaly and icterus was detected. In laboratory investigations, galactose1- phosphate uridyl transferase enzyme activity was normal, elevated direct bilirubin levels and transaminase levels were detected. Also, alpha fetoprotein level was very high at 767969 ng / mL (N: 46 ± 19). Blood amino acid analysis revealed high citrulline, methionine, tyrosine, threonine levels. SLC25A13 gene analysis revealed homozygous p. R319X (c.958C>T) mutation. Lactose (galactose) free diet was started, she was died at the age of 7 months. A two-year-old girl was admitted to our clinic with prolonged jaundice and increased in urine galactose when she was 4 months of age. Total galactose level was high. Galactose 1 phosphate and galactose- 1- phosphate uridyl transferase enzyme activity were normal. Blood amino acid analysis revealed elevated citrulline, threonine, methionine, tyrosine levels. In SLC25A13 gene analysis, p.L598 R (c.1793T> G) mutation was detected. Lactose (galactose) free diet was started. Regular follow up demonstrated normal growth and development. NICCD deficiency should be considered as a differential diagnosis in any infant with cholestasis and persistently positive urinary reducing substances. Lactose (galactose) free diet shows improvement in clinical and laboratory findings in these patients. The cases were presented in order to emphasize the importance of early diagnosis of the patients with NICDD.
383 - Argininosuccinate Synthetase Deficiency: Sixteen Patients From a Single Center
Ozden Durmus Gonultas1, Mehmet Cihan Balci2, Mubeccel Demirkol3, and Gülden Gökçay3
1Children’s Hospital, Istanbul Medical Faculty, Istanbul, Turkey
2Tokat State Hospital, Tokat, Turkey
3Division of Nutrition and Metabolism, Children’s Hospital, Istanbul Medical Faculty, Istanbul, Turkey
K) Organic Acidurias: Branched-Chain (384 to 415)
384 - Redox Homeostasis Disruption, Src Kinase Phosphorylation Increase, and Neuronal Damage Induced by the Major Accumulating Metabolites in 3-Hydroxy-3-Methylglutaric Aciduria in Rat Cerebral Cortex
Mateus Rosa1, Belisa Parmeggiani1, Mateus Grings1, Leonardo de Moura Alvorcem2, Nícolas Manzke Glänzel1, Renata Britto1, Moacir Wajner1, and Guilhian Leipnitz1
1Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
2Universadade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
3-Hydroxy-3-methylglutaric aciduria (HMGA) is a neurometabolic disorder characterized by predominant tissue accumulation and high urinary excretion of 3-hydroxy-3-methylglutaric (HMG) and 3-methylglutaric (MGA) acids. Affected patients predominantly present neurological symptoms, whose pathophysiology remains to be established. In the present work, we evaluated the effects of an acute intracerebroventricular (icv) administration of HMG and MGA on redox homeostasis, reactive oxygen species (ROS)-sensitive signaling pathways and neuronal damage in cerebral cortex of Wistar rats. One-day-old Wistar rats received icv injection of HMG (0.5 µmol/g), MGA (0.5 µmol/g) or PBS (control group; vehicle), and were euthanized 24 h after the administration. Cerebral cortex supernatants were then prepared to evaluate malondialdehyde (MDA) and reduced glutathione (GSH) levels, antioxidant enzyme activities and content of proteins involved in ROS-sensitive kinase phosphorylation pathways, as well as of Tau protein and synaptophysin, indicators of neuronal injury. HMG and MGA icv administration increased MDA levels and superoxide dismutase activity. We also verified that both organic acids decreased the activity of glutathione peroxidase, whereas only MGA diminished glutathione reductase activity and GSH concentrations, the most important cerebral antioxidant. Furthermore, HMG increased Src kinase phosphorylation, while decreased Tau protein phosphorylation and synaptophysin content. In contrast, HMG did not alter p38, ERK1/2 and JNK phosphorylation, and heme oxygenase-1 content. Our findings suggest that disruption of redox homeostasis caused by the metabolites accumulating in HMGA leading to Src kinase phosphorylation increase and neuronal damage are relevant pathomechanisms involved in the neurological dysfunction found in patients affected by this disorder.
385 - Autism Spectrum Disorder as a First Presentation of Propionic Acidemia
Daniela Avdjieva-Tzavella1, Hadil Kathom1, Maria Ivanova2, Radka Tincheva1
1Department of Clinical Genetics, University Pediatric Hospital, Medical University, Sofia, Bulgaria
2National Genetic Laboratory, University Hospital “ Majcin Dom”., Sofia, Bulgaria
Autism spectrum disorder (ASD) is a neurodevelopmental syndrome, diagnosed solely on the basis of the triad of persistent social and language deficits and stereotypic behaviors. Currently a genetic cause can be identified in 5% to 20% of children with ASD. Autism have been reported in association with inborn errors of metabolism (IEM) with a rate higher than that found in the general population. IEM can be found in less than 5% of autistic individuals. In these cases, autistic behavior is usually accompanied by clinical signs characteristic for IEM such as epilepsy, ataxia, lethargy, cyclic vomiting, and intellectual disability. In rare cases, however ASD may be considered as isolated at the onset of a metabolic disease. We describe a 3-year-old girl who was referred to the child psychiatrist because of behavioral problems such as repetitive and stereotyped movements, poor eye contact, isolation from other children. A diagnosis of ASD was made. Several months later she presented with severe metabolic acidosis, hyperammonemia, and hypoglycemia during a gastrointestinal infection. The patient was diagnosed with propionic academia (PA) after metabolic evaluation with tandem mass spectrometry and urine gas chromatography–mass spectrometry and a proper treatment was started. Early diagnosis of metabolic disorders in patients with autism is important because a timely treatment can improve behavioral disturbances.
386 - Identification of Six New Mutations on Chilean Population With Maple Syrup Urine Disease
Diana Campanholi1, José Simon Camelo Júnior2, Veronica Cornejo3, Ida V D Schwartz4, Ester Borges2, Wilson Araújo2, and Karen Campo3
1São Paulo University, São Paulo, SP, Brazil
2São Paulo University, Ribeirão Preto, SP, Brazil
3Chile University, Santiago, Chile
4Porto Alegre Clinical Hospital, Porto Alegre, RS, Brazil
387 - Experimental Evidence That the Metabolites Accumulating in Propionic Acidemia Impair NADH-Linked Oxidative Metabolism
Ana Cristina Roginski1, Cristiane Cecatto2, Kálita dos Santos Godoy2, Kaleb Pinto Spannenberger2, Moacir Wajner2, and Alexandre Umpierrez Amaral1
1Universidade Regional Integrada do Alto Uruguai e das Missões, Erechim, RS, Brazil
2Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
Propionic acidemia is an inherited metabolic disorder biochemically characterized by predominant accumulation of propionic (PA) and 3-hydroxypropionic (3OHPA) acids. Maleic acid (MA), a product of the intermediary metabolism structurally similar to PA, is also found at high concentrations in urine of these patients and was shown to provoke proximal tubule cell damage resembling Fanconi syndrome. Considering that patients affected by propionic acidemia usually develop chronic renal failure along development whose pathogenesis is yet unknown, we investigated the effects of MA, PA and 3OHPA on mitochondrial oxidative metabolism in mitochondrial preparations from kidney of young rats. Resting (state 4), ADP-stimulated (state 3) and CCCP-stimulated (uncoupled) respiration measured by oxygen consumption were evaluated using NADH- and FADH2-linked substrates, as well as the activities of α-ketoglutarate dehydrogenase (α-KGDH) and glutamate dehydrogenase (GDH). MA strongly decreased oxygen consumption in state 4, state 3 and uncoupled respiration using glutamate plus malate and especially α-ketoglutarate (up to 90%) as substrates, with less intense effects observed when using pyruvate plus malate and particularly succinate respiring mitochondria. In addition, PA moderately decreased state 3 and uncoupled respiration using pyruvate plus malate or glutamate plus malate-supported mitochondria (up to 40%), whereas 3OHPA provoked the less evident effects demonstrated by a mild decrease in states 4 and 3 respiration when mitochondria was supported by succinate (up to 20%). It was also observed that MA strongly decreased the activities of α-KGDH and GDH that may possibly be associated with the observed effects provoked by this organic acid on glutamate and α-ketoglutarate-supported mitochondria. It is therefore presumed that MA and PA but to a lesser extent behave as metabolic inhibitor of oxidative metabolism in kidney mitochondria and might be involved in the chronic renal failure occurring in propionic acidemic patients.
388 - Methylmalonic Aciduria in Saudi Patients: Report of Two Novel Homozygous Mutations in the Methylmalonyl-CoA Mutase Gene
Sarar Mohamed1 and Muddathir Hamad2
1Prince Sultan Military Medical City, Riyadh, Saudi Arabia
2King Saud University Medical City, Riyadh, Saudi Arabia
389 - 3-Hydroxy-3-Methylglutaryl-CoA Lyase Deficiency: A Case Report and Literature Review
Ozlem Yilmaz1, Steve Kitchen2, Alex Pinto2, Anne Daly2, Rachel Hoban2, Saikat Santra2, Srividya Sreekantam2, Kathryn Frost3, Anna Pigott3, and Anita Macdonald2
1Hacettepe University, Ankara, Turkey
2Birmingham Children’s Hospital, Birmingham, United Kingdom
3Royal Stoke University Hospital, Stoke-On-Trent, United Kingdom
390 - Elucidating the Mitochondrial Architecture of Branched-Chain Amino Acid Metabolism Enzymes
Stephen Mccalley1, Yudong Wang2, Simon Watkins1, Claudette St. Croix1, Thomas Roddy3, Kendall Johnson3, Michael Calderon1, and Jerry Vockley2
1University of Pittsburgh, Pittsburgh, PA, USA
2Children's Hospital of Pittsburgh Upmc, Pittsburgh, PA, USA
3Agios Pharmaceuticals, Cambridge, MA, USA
391 - Oxysterol Levels in Organic Acidemia Patients: Preliminary Results
Yasemin Eraslan1, Incilay Lay2, Afshin Samadi2, Berrak Bilginer Gurbuz3, Ali Dursun3, Serap Sivri3, and Turgay Coskun3
1Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
2Department of Medical Biochemistry, Hacettepe University Faculty of Medicine, Ankara, Turkey
3Pediatric Metabolic Diseases Unit, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
392 - Exposure of Normal Human Primary Hepatocytes to Propionate Replicates Aspects of Biochemical Features in Propionic Acidemia
Kimberly Chapman1, Robert Figler2, Allison Armstrong2, Stephen Hoang2, Marshall Summar1, John Reardon2, Brian Wamhoff2, and M.Sol Collado2
1Children’s National Medical Center, Washington, DC, USA
2Hemoshear Therapeutics, Charlottesville, NC, USA
Propionic acidemia (PA) is an autosomal recessive disorder of propionate catabolism caused by a deficiency in the enzyme propionyl CoA carboxylase (PCC). The functional consequence of PCC deficiency is the inability to catabolize propionyl-CoA (P-CoA) to methylmalonyl-CoA, resulting in the accumulation of P-CoA and other metabolic intermediates, such as propionylcarnitine, 3-hydroxypropionic acid, and methylcitrate. P-CoA, at the high concentrations found in PA, causes the inhibition of liver N-acetylglutamate synthetase (NAGS), impacting ureagenesis and inducing hyperammonemia. In addition, P-CoA and its metabolic intermediates reduce mitochondrial energy production by inhibition of enzymes in the tricarboxylic acid (TCA) cycle. We previously showed that metabolic defects of PA could be recapitulated using PA patient-derived primary hepatocytes in a novel organotypic system (Chapman et al, MGM 2016). Here, we sought to investigate whether propionate treatment of normal human primary hepatocytes would recapitulate some of the biochemical features of PA in the same platform. We found that high levels of propionate resulted in high levels of intracellular P-CoA in normal hepatocytes similar to the levels found in PA hepatocytes. Propionate treatment also induced increases in ammonia and decreases in urea. Analysis of TCA cycle intermediates indicated that propionate is incorporated in the TCA cycle. However, the pattern of regulation of TCA intermediates, suggested that propionate treatment may also inhibit enzymes of the TCA cycle as shown in PA. In summary, propionate treatment on normal primary hepatocytes recapitulates some key biochemical features of PA.
393 - To Understand Genetic and Biochemical profiles in Indian Patients With Glutaric Aciduria Type I
Tp Kruthika-Vinod and Muntaj Shaik
National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
394 - Clinical, Molecular Data and Outcome of 25 Iranian Patients Affected of Isolated Methylmalonic Aciduria: A Case Series
Shirin Moarefian1, Ali Rahmanifar1, Mahdi Zamani2, and Talieh Zaman3
1Iranian National Society for Study on Inborn Errors of Metabolism, Tehran, Iran
22-Department of Neurogenetics, Iranian Center of Neurological Research, Tehran University of Medical, Tehran, Iran
3Department of Metabolism, Children Medical Center, School of Medicine, Tehran University of Medical, Tehran, Iran
395 - Together: Methylmalonyl CoA Mutase and Oxoglutarate Dehydrogenase Complex Associate With the Inner Mitochondrial Membrane
Kimberly Chapman, Elena Pumbo, and Parith Wongkittichote
Children’s National Medical Center, Washington, DC, USA
396 - Potential Role of miRNAs in the Development of Cardiomyopathies in Propionic Acidemia
Alejandro Fulgencio-Covián1, Ana Rivera-Barahona1, Esmeralda Alonso-Barroso1, Belen Pérez1, Michael A. Barry2, Magdalena Ugarte3, Celia Pérez-Cerdá3, Eva Richard1, and Lourdes R. Desviat1
1Centro de Biología Molecular Severo Ochoa, Madrid, Spain
2Mayo Clinic, Rochester, MN, USA
3Centro de Diagnóstico de Enfermedades Moleculares (Cedem), Madrid, Spain
Propionic acidemia (PA) is a potentially lethal autosomal–recessive organic aciduria caused by defects in either the PCCA or the PCCB genes, encoding both subunits of the mitochondrial enzyme propionyl-CoA carboxylase (PCC). Considering the natural history of the disease, cardiac alterations (hypertrophy, dilated cardiomyopathy, long QT) are one of the major causes of mortality in patients surviving the neonatal period. We have previously identified a set of dysregulated miRNAs involved in apoptosis and mitochondrial function in tissue samples of the hypomorphic Pcca −/−(A138 T) mouse model of the disease and in PA patients’ plasma samples. In this work, we set out to investigate miRNAs highly expressed in cardiac tissue and reported to be involved in cardiomyopathies (cardiomiRs). A group of 11 cardiomiRs were selected (miR-1, miR-23a, miR-29a, miR-30c, miR-34a, miR-133a, miR-199a, miR-208a, miR-328, miR-350, and miR-378), with a documented relevant role in cardiac hypertrophy, apoptosis or fibrosis. Our results showed that all miRNAs analyzed except miR-328 were upregulated in heart samples from hypomorphic PA mice, as compared to wild type mouse samples. For the upregulated miRNAs, we have investigated their role in signaling pathways involved in the development of cardiac disease, through the analysis of reported direct or indirect downstream targets. For anti-apoptotic miR-133a, that protects cardiomyocytes from oxidative stress induced apoptosis, we detected a decrease in the levels of its target caspase 3. The increase in pro-hypertrophic miR-199a correlated with the decrease in its target PPARδ, a critical regulator of energy metabolism. Finally, pro-hypertrophic miR-208a, one of the most important heart-enriched miRNAs playing a crucial role in heart disease, was found 16-fold increased correlating with the increase of the pro-hypertrophic marker β-MHC, regulated by the transcription factor MED13, which is directly repressed by miR-208a. Recently, the identification of miR-208a and other cardiomiRs in plasma has fostered their clinical interest as potential biomarkers of cardiac injuries. We could detect increased levels of miR-208a in pooled plasma samples from PA patients, paving the way for more in-depth studies of cardiomiRs as biomarkers and therapeutic targets for heart disease in PA patients.
397 - Methylmalonic Aciduria cblB Type: Hepatocyte Differentiation From iPS
Eva Richard, Sandra Brasil, Alvaro Briso-Montiano, Lourdes R. Desviat, Magdalena Ugarte, and Belen Pérez
Centro de Diagnóstico de Enfermedades Moleculares, Universidad Autonoma de Madrid, Ciberer, Madrid, Spain
The understanding of the cellular and molecular mechanisms underlying inherited metabolic disorders (IMDs) is essential for devising new strategies for their prevention and treatment. The difficulty to obtain a unique model for all the genotypes observed in IMDs and the upcoming of personalized medicine has prompted the emergence of new models. The aim of this work was the hepatocyte differentiation of induced pluripotent stem cells (iPSCs) generated by reprogramming of methylmalonic aciduria cblB type patient-derived fibroblasts. This organic aciduria is caused by the deficiency of ATP: cob(I)alamin adenosyltransferase (ATR) encoded by the MMAB gene. Fibroblasts from a patient bearing a hypomorphic destabilizing mutation in the MMAB gene (p.Ile96Thr) were reprogrammed using the commercial CytoTune Sendai vectors. After the molecular and functional characterization of the iPS cell line, iPSCs were differentiated in vitro into definitive endoderm and then incubated with specific factors, aimed at hepatocyte differentiation. IPSC-derived hepatocytes expressed relevant hepatic markers (HNF4a, AFP and albumin) analyzed by immunofluorescence. HepaRG, a hepatoma cell line highlighted for its high and inducible drug-metabolizing enzyme activities, was also used in the study to compare the expression of hepatic markers. Finally, the hepatocytes generated were used for evaluation of a potential pharmacological chaperone previously described (N-{[(4-chlorophenyl)carbamothioyl]amino}-2-phenylacetamide) in combination with hydroxocobalamin. The results provide evidences of its positive effect on the activity of the mutant ATR hepatocytes. Hence, our findings provide an experimental suitable model for the investigation of the pathogenesis of this severe disease serving also as ex vivo platform for therapeutic applications.
398 - Successful Living Donor Liver Transplantation for Classical Maple Syrup Urine Disease
Cigdem Seher Kasapkara1, Mustafa Kiliç1, Ahmet Baştürk2, Ilyas Okur3, and Leyla Tümer3
1Dr. Sami Ulus Children’s Hospital, Ankara, Turkey
2Akdeniz University, Antalya, Turkey
3Gazi University, Ankara, Turkey
MSUD is an autosomal recessive condition characterized by a deficiency in the enzyme, BCKDH, which catalyzes the breakdown of BCAAs. If left untreated, MSUD can result in mental retardation, central nervous system disorders, and even death. Most patients with MSUD are treated with a restricted protein diet and milk from which BCAAs have been removed. During times of illness, patients with MSUD can suffer from severe metabolic derangement, acute cerebral edema, and untimely death. Liver transplantation has been shown effective in patients with MSUD. Donor liver transplant restores the ability to metabolize branched-chain amino acids, even on an unrestricted diet, and prevents metabolic derangements during times of illness. This report describes the case of a 38-month-old boy with classical MSUD who received a liver graft from his mother at the age of 10-month-old. Transplantation was successful, and the patient was then able to ingest a normal diet. Post-operative BCAA levels normalized in our patient and remained so on an unrestricted protein diet and during times of physiological stress. Following transplantation, he did not require hospitalization in the last 28 months nor did any have new acute metabolic attack following a normal diet. He has excellent neurologic examination. These findings indicate that patients with MSUD can be successfully treated by LDLT, even when the donor is a heterozygous carrier of a mutated BCKDH gene.
399 - Alternating Hemiplegia as a Major Symptom of Maple Syrup Urine Disease: Case Report
Luisa Simonsen, Natasha Geisel, Nathalia Fernandes, Julia Albuquerque, Andreia Moreira, Marlos Martins, Krizia Dias, Helio Rocha, Debora Fogaça, Talita Leal, Diogo Silva, Cinthya Fernandes, Aline Chacon, Giuseppe Pastura, Flavia Nardes, Alexandra Prufer, Karly Lagreca, Marcelle Soares, Mariana Kappaun, and Marilia Bezerra
Ippmg Ufrj, Rio de Janeiro, RJ, Brazil
The aim of the present study is to draw attention to the rare association of maple syrup urine disease and alternating hemiplegia. We describe a case report from medical record review. RFD, 3 years and 6 months, male, white, adopted 3 months before, had abrupt onset of paroxysmal motor events characterized by alternating hemiplegia, with a duration of 30 minutes, evolving with total and spontaneous recovery in up to 24 hours, totaling 28 in 6 months. There was no information on prior development and symptoms of the child currently presenting language and fine motor delay. The physical exam showed dimorphisms: absence of lip groove, thin upper lip, large eyes, thick eyebrows, blond and fine hair, brachydactyly, hypotrophy, hypotonia, hyperreflexia, and low weight. Magnetic resonance imaging of the brain was performed with spectroscopy revealing hypersignal of globus pallidus, subthalamic nuclei, thalamus, mesencephalon and dentate nuclei; restriction areas in the cerebellar hemisferes and hypersignal in subcortical white matter; branched chain amino acid spike. Analysis of urinary organic acids showed elevated levels of 3-hydroxybutyric acid, 2-hidroxisovaluric,2-hidroxi-3-metilvaluric,2-hidroxisocaproic and 2- ketoisocapric acids, leucine, and isoleucine. The patient was diagnosed with MSUD and experienced resolution of neurological symptoms and milestones improvement after treatment with restriction of protein intake. MSUD has a worldwide incidence of 1: 185 000 live births and is not present in neonatal screening in our country, despite having treatment that alters the course of the disease. They can be divided into classical form and variants, that can vary according to the residual enzymatic activity. In the presenting case the lack of information of years previous to the adoption, associated with the rare atypical manifestation, lead to a difficulty in clinical suspicion and diagnosis. Despite the compatible laboratory and radiological diagnosis and good response to therapy for MSUD, gene sequencing was already requested for diagnostic confirmation of the subtype of the disease. There are only a few reports of the association between MSUD and alternating hemiplegia, making effective recognition and treatment a challenge. Therefore, it is necessary to approach the subject in order to improve these patient’s morbidity and mortality, preventing the progress of neurological deficits.
400 - Improved Clinical Outcome Following Use of Citrate for Anaplerosis in Propionic Acidemia
Saikat Santra, Julian Raiman, Srividya Sreekantam, Anne Daly, Adam Gerrard, Suresh Vijayaraghavan, and Mary Anne Preece
Birmingham Children’s Hospital, Birmingham, United Kingdom
401 - Cardiac Manifestations of Propionic Acidemia and Methylmalonic Aciduria: A Systematic Retrospective Review
Nandaki Keshavan1, Massimiliano Lorenzini2, Georgi Christov3, Steve Krywawych4, Elaine Murphy5, and Stephanie Grunewald6
1Department of Paediatric Metabolic Medicine, Great Ormond Street Hospital NHS Trust, London, United Kingdom
2University College London Institute for Cardiovascular Science and Barts Heart Centre, London, United Kingdom
3Cardiothoracic Unit Great Ormond Street Hospital, London, United Kingdom
4Chemical Pathology Department, Great Ormond Street Hospital, London, United Kingdom
5Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, United Kingdom
6Institute of Child Health, University College London, London, United Kingdom
402 - Acute Metabolic Decompensations of Branched-Chain Organic Acidemias in the Pediatric Emergency Department: Clinical Presentation and Outcomes
Serap Sivri, Yilmaz Yildiz, Leman Akcan Yildiz, Emine Goksoy, Berrak Bilginer Gurbuz, Ali Dursun, Ayşegül Tokatli, Turgay Coskun, and Özlem Tekşam
Hacettepe University, Ankara, Turkey
Branched-chain organic acidemias are a group of inborn errors of metabolism characterized by recurrent life-threatening acute metabolic decompensations (AMD). There is no single clinical or biochemical marker established by consensus or strong evidence to diagnose AMD. However, presence of vomiting, food refusal or altered consciousness has been previously proposed to diagnose AMD in methylmalonic acidemia (MMA) and propionic acidemia (PA). In this study, we aimed to retrospectively analyze the clinical presentations and outcomes of patients with MMA, PA, isovaleric acidemia (IVA) and maple syrup urine disease (MSUD) that presented to the emergency department of a single metabolic center in Turkey. Children with MMA, PA, IVA, and MSUD that presented for any reason to the emergency department of Hacettepe University Children’s Hospital during 2014-2016 were included. Clinical data were retrieved from hospital records. There were a total of 67 patients (20 MMA, 16 PA, 5 IVA, and 26 MSUD) and 278 presentations (90 MMA, 94 PA, 7 IVA, and 87 MSUD). 36.6% of all presentations (102 distributed as 17 MMA, 57 PA, 2 IVA, and 26 MSUD) were diagnosed as AMD. Presence of vomiting, food refusal, or altered consciousness did not significantly differ between MMA patients with or without AMD (P > .05), but all three of these clinical findings were significantly more common in PA patients with AMD than those without AMD (P < .0001, P < .01, and P < .05, respectively). In MSUD, altered consciousness was significantly more prevalent in those with AMD (P < .001), but vomiting and food refusal were not (P > .05). During the study period, 1 patient with PA died during an AMD. 2 MMA patients without an AMD died due to sepsis, which, in 1 patient, was precipitated by loss of protective skin and mucosa barrier due to severe isoleucine deficiency. Although MMA and PA are similar diseases in a common metabolic pathway, vomiting, food refusal, and altered consciousness were significantly more prevalent in AMD of patients with PA, but not with MMA. Vomiting and food refusal are common complaints that can be attributed to other causes in pediatric practice, such as acute infections or chronic diseases. Other clinical and laboratory parameters are necessary to differentiate these causes from AMD in patients with organic acidemias. It is important to note that deaths may not always be due to AMD. Infections and treatment complications should be prevented and treated to decrease mortality.
403 - Successful Management of Methylmalonic Aciduria During Pregnancy and Delivery—Case Report
Jolanta Sykut-Cegielska1, Agnieszka Kowalik1, Monika Hanyz2, Joanna Taybert3, Ewa Jablonska1, Katarzyna Kusmierska1, Tomasz Polawski1, Mariusz Oltarzewski1, and Tomasz Maciejewski2
1Screening and Metabolic Diagnostics Dep, Institute of Mother and Child, Warsaw, Poland
2Obstetrics and Gynecology Dep, Institute of Mother and Child, Warsaw, Poland
3Metabolic Outpatient Clinic, Warsaw, Poland
404 - Cognitive Development and Emotional Features in Chilean Patients With MSUD
Alicia de La Parra, Maria Ignacia García, and Castro Chaves
Inta Universidad de Chile, Santiago, Chile
Maple syrup urine disease (MSUD) is an inborn error of amino acids catabolism characterized by the accumulation of branched-chain amino acids leucine, isoleucine and valine and their corresponding neurotoxic ketoacids. Little information regarding behavioral development of these patients is available. The aim of this study was then to analyze long term cognitive development and observed emotional and behavioral features in MSUD patients. This retrospective study included 41 Chilean patients, 35 with classic form MSUD. The mean age of diagnose was 38.9 ± 96 days (3-600 d) with a mean leucine concentration of 1456 ± 854 µmol/L. Mean age last psychomotor development assessment with Bayley Scale of Infant Development of 31.7 ± 12.5 months, mean mental index score (MDI) was 55.1 ± 12.5. Only 24% patients showed normal development or mild delay (MDI > 70). The mean age last IQ assessment was 12.6 ± 3.6 years of age (5-20 years), all assessed with age-appropriate Wechsler Intelligence Scale, showing a mean verbal IQ (VIQ) of 65.2 ± 22.5, performance IQ (PIQ) of 60.6 ± 20.5 and full-scale IQ (FSIQ) of 61.1 ± 20.8 (39-103). 18% of patients showed a normal cognitive functioning (FSIQ 80-109), 34% borderline or mild disability and 46.9% moderate to severe cognitive disability. Of the 6 children that presented normal cognitive functioning, two had normal psychomotor development during infancy, two mild and two severe developmental delays. Of the patients that scored FSIQ >55 (n = 17), 9 presented lower scores in the PIQ when compared with the VIQ, with an average of 15.2 points of difference. Regarding observed behaviors, in patients with FSIQ>55 score, 14/17 patients were described as smiling, having good social response and 12 showed attention difficulties and/or mild restlessness/impulsive behaviors. In the group FSIQ<55, 18/21 showed good social response, but 15 of them had serious attentional difficulties and/or restlessness/impulsive behavior. Children diagnosed before the 14th day of life (9 ± 3.3 d, n = 18) presented a significantly better FSIQ (74 ± 19.7 vs 53 ± 18 ρ = 0.001) that the group of children diagnosed after (61 ± 124 d, n = 17).
405 - Unusual Triple Troubles of Genetic Disorders Lead to Clinical Presentations
Wei Wang1, Victor Wei Zhang2, Xiaoping Lan1, Juan Wang1, Yongchen Yang1, Chagrin Xia1, Moher Xu1, and Victor Wei Zhang3
1Shanghai Children’s Hospital, Shanghai, China
2Baylor College of Medicine, Houston, TX, USA
3Amcare Genomics Lab, Guangzhou, China Popular Republic
406 - MSUD: Levels of Leucine, Isoleucine, Valine, and Alloisoleucine During the First Seven Days of Life in Maple Syrup Urine Disease
Romina Rodriguez, María Inés Otegui, and Hernán Eiroa
Hospital de Pediatría “J.P.Garrahan,” Buenos Aires, Argentina
Maple Syrup Urine Disease (MSUD) results from a primary defect in oxidative decarboxylation of the ketoacids derived from the branched chain amino acids: leucine (leu), isoleucine(ile) valine(val) and alloisoleucine (alloile). Neonates with classic MSUD appear normal at birth but usually become symptomatic by 4 or 5 days of age. There are very few serial data available on the levels of branched chain amino acids at birth and through the first few days in neonates with this disease.
407 - Molecular Characterization of Maple Syrup Urine Disease in Tunisia
Kamel Monastiri1, Fatma Zohra Chioukh1, Karim Ben Ameur1, Emna Kerkeni1, and Cécile Acquaviva2
1Department Icu And Neonatal Medicine, Research Unit 01/Ur/08.14 Faculty Of Medicine, Monastir, Tunisia
2Laboratoire Biologie Medicale Multi Sites Du Chu de Lyon, Centre de Biologie Et Pathologie Est, Lyon, France
408 - Early Diagnosis of Neonatal Classical Maple Syrup Urine Disease By 1H-MRS
Kamel Monastiri, Fatma Zohra Chioukh, Karim Ben Ameur, and Hayet Ben Hmida
Department ICU and Neonatal Medicine, Research Unit 01/Ur/08.14, Faculty of Medicine, Monastir, Tunisia
409 - Organic Acidurias and Other Inborn Errors of Metabolism Detected by Urinary Organic Acid Analysis: A 10-Year Period Experience of a Private Laboratory in Brazil
Eduardo Vieira Neto1, Luiz Nelson Lopes Ferreira Gomes2, Armando Fonseca2, and Jacqueline Harouche Rodrigues da Fonseca2
1Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
2Laboratório Diagnósticos Laboratoriais Especializados, Rio de Janeiro, RJ, Brazil
410 - Effect of Liver Transplantation on Hyperammonemia and Metabolic Control in Propionic Acidemia
Nicola Longo
University of Utah, Salt Lake City, UT, USA
Propionic acidemia is caused by a deficiency of propionyl- CoA carboxylase, the enzyme that converts propionyl-CoA to methylmalonyl-CoA. In its most severe form, it is characterized by recurrent episodes of hyperammonemia and metabolic acidosis resulting in progressive encephalopathy and organ damage. The objective of this study was to evaluate the effects of heterologous orthotopic liver transplantation on biochemical control and clinical outcome in 3 patients with propionic acidemia. Biochemical and clinical data were collected by retrospective review of medical records. All patients were followed at our center since birth, and all data were used for analysis. Values of continuous variables before and after transplantation were compared using analysis of variance. Three of our patients with neonatal presentation of propionic acidemia underwent orthotopic unrelated liver transplantation at 0.75-13 years of age. All patients tolerated the procedure well and were discharged home 16-26 days after the procedure. There was a decrease in plasma C3 (propionyl)-carnitine (from 81.4 ± 16.4 to 47.3 ± 14.3 µmol/L) and glycine (from 921 ± 397 to 359 ± 126 µmol/L) after the liver transplant with an increase in glutamine (a marker of anaplerosis, from 373 ± 127 to 556 ± 98 µmol/L). Ammonia levels were significantly reduced (from 77.6 ± 42.7 to 43 ± 22.9 µmol/L) after the transplant with no new hyperammonemic events (follow-up time 1.6-3.9 years). Number and length of hospital admissions (normalized per year) decreased significantly after transplant. Patients had improvements of developmental milestones, decreased the use of medical foods (although supplements of carnitine and citrate were continued) and increased the intake of natural proteins. These data indicate that liver transplant can improve metabolic control and quality of life in patient with severe forms of propionic acidemia, while reducing hospital admissions. Liver transplant remains a procedure with considerable risk and longer follow-up is necessary to determine the overall risk–benefit ratio in propionic acidemia.
411 - Methylmalonic Aciduria as a Differential Diagnosis of Primary Immune Deficiencies: A Case Report
Rim Ben Abdelaziz1, Arij Ayadi2, Hela Hajji2, Amel Ben Chehida1, Hela Boudabous1, Awatef Jlassi3, Mohamed Slim Abdelmoula1, Moncef Fekih3, Hatem Azzouz1, and Neji Tebib1
1 Faculté de Médecine de Tunis, La Rabta Hospital, Université Tunis Elmanar, Tunis, Tunisia
2La Rabta Hospital, Tunis, Tunisia
3Laboratory of Biochemistry, La Rabta Hospital, Tunis, Tunisia
412 - Recurrent Hypoglycaemia Revealing a Propionic Aciduria: A Case Report
Rim Ben Abdelaziz1, Arij Ayadi2, Hela Hajji2, Hela Boudabous1, Amel Ben Chehida1, Awatef Jlassi3, Mohamed Slim Abdelmoula1, Moncef Fekih3, Hatem Azzouz1, and Neji Tebib1
1Faculté de Médecine de Tunis, La Rabta Hospital, Université Tunis Elmanar, Tunis, Tunisia
2La Rabta Hospital, Tunis, Tunisia
3Laboratory of Biochemistry, La Rabta Hospital, Tunis, Tunisia
413 - Glutaric Aciduria III in Female Patient Detected Through Chromosomal Microarray Analysis (CMA 750 k CGH+SNP)
Hugo Hernán Abarca Barriga, Milana Trubnykova, Miguel Angel Chavez Pastor, and Ximena Montenegro Garreaud
Instituto Nacional de Salud Del Niño, Lima, Peru
We present an 8-year-old female patient with development delay and intellectual disability. Parents weren’t consanguineous. Family history was positive for schizophrenia on a paternal uncle. Medical history: vaginal delivery, weight birth 3,500 g, height birth and cephalic perimeter are unknown. On physical examination, short stature, microcephaly, underdeveloped supraorbital ridges, short, woolly, sparse hair; trichorrhexis nodosa (optical microscopy) and bilateral clinodactyly was found. Developmental milestones: walking at 3 years 6 months old, first words at 4 years old, currently on elementary school (1st grade). Chromosomal microarray analysis showed homozygous deletion of 125 kb on chromosome 7 [7p14.1(40,140,770-40,265,451)x0], compromised two genes: MPLKIP, C7orf10, producing two entities: Trichothiodystrophy 4, non-photosensitive (TTD4) and glutaric aciduria III (GA III). Although patients with GA III may have no disease phenotype, some patients showed failure to thrive, hypertension, diarrhea, vomiting, goiter and hyperthyroidism. All patient's clinical characteristics are due to TTD4, and C7orf10 deletion is probably asymptomatic.
414 - Experimental Evidence That α-Ketoadipic and α-Aminoadipic Acids Provoke Marked Oxidative Damage and Reduces the Antioxidant Defenses in Rat Brain
Janaína Camacho Silva1, Alexandre Umpierrez Amaral1, Cristiane Cecatto1, Alessandro Wajner1, Kálita dos Santos Godoy1, Rafael Teixeira Ribeiro1, Lucas Henrique Rodrigues da Silva1, Ângela Zanatta1, Mateus Struecker da Rosa1, Samanta Oliveira Loureiro1, Carmen Regla Vargas2, Guilhian Leipnitz1, Diogo Onofre Gomes de Souza1, and Moacir Wajner1
1Depto de Bioquímica, Icbs, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
2Serviço de Genética Médica, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
α-Ketoadipic aciduria is biochemically characterized by tissue accumulation and high urinary excretion of α-ketoadipic (KAA) and α-aminoadipic (AAA) acids. Although many patients are asymptomatic, especially those diagnosed by NBS at birth, many others present neurological symptoms of unknown pathogenesis. We investigated the in vitro effects of KAA and AAA on a large spectrum of redox homeostasis parameters in brain of young rats. 2′,7′-Dichlorofluorescein (DCFH) oxidation, nitrate and nitrite levels, malondialdehyde (MDA) concentrations, carbonyl formation, sulfhydryl content, glutathione (GSH) concentrations and aconitase activity were determined in rat cerebral cortex. AAA and more markedly KAA increased reactive oxygen and nitrogen species (increase of DCFH oxidation and nitrite/nitrate levels) generation as well as induced lipid (increase of MDA concentrations) and protein oxidative damage (increase of carbonyl formation and decrease of sulfhydryl content), besides decreasing the antioxidant defenses (reduced glutathione, GSH) and aconitase activity. We also observed that KAA-induced lipid peroxidation and GSH decrease were prevented by the antioxidants α-tocopherol, melatonin and resveratrol, suggesting the involvement of reactive species in these effects. Furthermore, the classical inhibitors of NMDA glutamate receptors MK-801 and memantine did not prevent KAA- and AAA-induced reactive species formation (increase of DCFH oxidation) and GSH levels decrease, making unlikely a secondary induction of oxidative stress through overstimulation of glutamate receptors. The present data indicate that disturbance of redox homeostasis by the major metabolites that accumulate in α-ketoadipic aciduria may possibly contribute to the pathophysiology of the neurologic symptoms occurring in some affected patients.
415 - Delayed Diagnosis of Glutaric Aciduria Type 1 (GA1): Clinical Case Report
Juan Carlos Velasquez Ramirez, Beena Devanapalli, Carolyn Ellaway, and Kevin Carpenter
The Sydney Children’s Hospital Network, Sydney, Australia
L) Organic Acidurias: Others (416 to 440)
416 - Simultaneous Estimation of Elevated Biomarkers of Organic Acidemia in Neonatal Urine using LC-MS
Sudheer Moorkoth1, Violet D’ Mello1, and Pragna Rao2
1Department of Pharmaceutical Quality Assurance, Manipal University, Manipal, India
2Department of Biochemistry, Kasturba Medical College, Manipal University, Manipal, India
Inherited metabolic disorders include a variety of disorders which are individually rare but frequently observed, affecting the pediatric population causing mortality or morbidity. Despite the advancements in bioanalytical methods, it still remains a challenge to the analysts to develop a method for small molecules in complex matrices. The LC-MS technique clubbed with the separation power of HILIC column technology has given sufficient specificity and sensitivity avoiding derivatization. In this study, an LC-MS based analytical method was developed and validated for screening of biomarkers responsible for maple syrup urine disease and methyl malonic aciduria. This method has achieved recoveries of 80%-105% by a “dilute and shoot” method, thus avoiding time consuming extraction techniques. Complete separation of all biomarkers and the internal standard were achieved within a retention time of 3.6 minutes. The intra and inter-day precision were < 11% and 12%, respectively, with linearity r 2 of ≥ 0.990 for biomarkers in their respective calibration ranges. The stability studies for the biomarkers were promising at all stability study conditions. Analyses of clinical samples with the developed method were in confirmation with the gold standard techniques such as GC-MS and tandem mass spectrometry. The method was applied for analysis of samples for confirmation of maple syrup urine disease and methylmalonic acidemia.
417 - Oxidative Stress in Patients With L-2-Hydroxyglutaric Aciduria and In Vitro Protective Effect of L-carnitine Upon DNA Damage Caused by D-2-Hydroxyglutaric and L-2-Hydroxyglutaric Acids
Daiane Grigolo Bardemaker Rodrigues1, Daniella de Moura Coelho2, Angela Sitta2, Carlos Eduardo Diaz Jacques1, Tatiane Hauschild1, Natália Forest3, Vanusa Manfredini4, Abdellatif Bakkali5, Eduard Struys5, Cornelis Jakobs5, Mand oacir Wajner2, and Carmen Regla Vargas1
1Programa de Pós-Graduação Em Ciências Farmacêuticas, Faculdade de Farmácia, Ufrgs, Porto Alegre, RS, Brazil
2Serviço de Genética Médica, Hcpa, Porto Alegre, RS, Brazil
3Universidade Federal do Rio Grande do Sul, Faculdade de Farmácia, Porto Alegre, RS, Brazil
4Universidade Federal do Pampa, Uruguaiana, RS, Brazil
5Metabolic Unit, Clinical Chemistry, Vims Medical Center, Amsterdam, the Netherlands
D-2-hydroxyglutaric (D-2-HGA) and L-2-hydroxyglutaric acidurias (L-2-HGA) are 2 distinct neurometabolic disorders biochemically characterized by increased levels of D-2-hydroxyglutaric (D-2-HG) and L-2-hydroxyglutaric acids (L-2-HG) in biological fluids and tissues, respectively. Patients affected by D-2-HGA are classified into 2 variants, D-2-HGA type I or D-2-HGA type II. D-2-HGA type I is caused by mutation of D-2-hydroxyglutarate dehydrogenase gene while D-2-HGA type II is caused by a gain of function mutation in isocitrate dehydrogenase 2 gene. L-2-HGA is caused by mutation in the L-2-hydroxyglutarate dehydrogenase gene. Considering that the pathophysiology of these diseases is not fully understood and that many studies have been shown the involvement of oxidative stress in inborn errors of metabolism, the main objective of this work was to investigate oxidative and nitrative stress parameters in the urine of L-2-HGA patients and to investigate the in vitro DNA damage caused by the accumulated acids of D-2-HGA and L-2-HGA as well as the protective effect of L-carnitine on this damage. It has been found that concentrations of 50 µM of D-2-HG and 30 µM of L-2-HG induce DNA damage and concentrations of 30 µM and 150 µM of L-carnitine significantly reduced the in vitro DNA damage, measured by comet assay, compared to controls. In addition, urine samples from L-2-HGA patients were analyzed. It was observed a significant increase of oxidized guanine species, an oxidative DNA damage biomarker as well as a significant increase of urinary di-tyrosine level, indicating protein oxidative damage in the patients. However, there was no significant difference in the levels of urinary isoprostanes and reactive nitrogen species. In conclusion, these results suggest, at least in part, proteins and DNA oxidative damage and highlight the L-carnitine antioxidant potential as a promising adjuvant in the treatment of patients affected by L-2-HGA or D-2-HGA.
418 - Striatum Histopathological Alterations Provoked by Acute Lysine Administration in Glutaryl-CoA Dehydrogenase Deficient Mice
Moacir Wajner1, Bianca Seminotti2, Janaína Camacho Silva2, Rafael Teixeira Ribeiro2, Ramiro Cavedon Nunes2, Francine Hehn de Oliveira3, Guilhian Leipnitz2, Diogo Onofre Gomes de Souza2, and Alexandre Umpierrez Amaral2
1Serviço de Genética Médica, Hospital de Clínica de Porto Alegre, Porto Alegre, RS, Brazil
2Depto de Bioquímica, Icbs, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
3Serviço de Patologia, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
Glutaric acidemia type I (GA I) is an inborn error of lysine (Lys) catabolism caused by glutaryl-CoA dehydrogenase (GCDH) deficiency. Patients affected by this disorder are highly susceptible to develop striatum acute degeneration during stress catabolic situations mainly from 3 to 36 months of age that significantly worse their prognosis. Although the underlying mechanisms of striatum damage are still on debate, they may be related to increased brain concentrations of glutaric (GA) and 3-hydroxyglutaric acids. In the present work, we investigated the effects of an acute intrastriatal administration of Lys (1.5 and 4 µmol) to 30-day-old wild type (WT) and GCDH deficient (Gcdh−/−) mice fed a baseline chow (0.9% Lys) on brain histopathology. Mice were sacrificed 48 hours after Lys injection. Striatum and cerebral cortex morphology was evaluated by hematoxylin and eosin, whereas astrocyte activation and neuronal viability were determined by immunohistochemistry of GFAP and NeuN, respectively. Lys administration at the lowest dose (1.5 µmol) provoked marked vacuolation/edema in the striatum of Gcdh−/− but not in WT mice, implying a higher susceptibility of Gcdh−/− mice to acute intrastriatal Lys. Similarly, astrocytic GFAP protein staining was markedly increased only in Gcdh−/− Lys (1.5 µmol)-injected mice, suggesting astrocytic reactivity. Furthermore, NeuN staining was reduced in the striatum of Gcdh−/− but not in WT mice submitted to 1.5 µmol Lys treatment, indicating neuronal loss. It is stressed that no alterations were observed in the cerebral cortex of both WT and Gcdh−/− mice injected with 1.5 µmol Lys. However, Lys, at the highest dose (4 µmol), also provoked extensive vacuolation in cerebral cortex of Gcdh−/− mice, as compared to WT mice, indicating that cerebral cortex of GCDH deficient mice may be also affected in the knockout animals when exposed to high Lys concentrations. It is concluded that striatum of Gcdh−/− mice is severely damaged presenting astrogliosis and neuronal loss when acutely injected with Lys that is presumably converted to GA and possibly 3HGA in the brain of these animals. The present data therefore support the hypothesis that increased brain concentrations of the accumulating metabolites may be responsible for the striatal damage occurring in GA I patients during episodes of metabolic decompensation.
419 - Cobalamin C Deficiency Detected Through Family Screening and Treated Prenatally—Case Report
Jolanta Sykut-Cegielska1, Monika Hanyz2, Alicja Karney3, Marcin Kalisiak4, Joanna Taybert5, Alicja Goszczanska-Ciuchta6, Malgorzata Seroczynska4, Agnieszka Kowalik1, Ewa Jablonska1, Katarzyna Kusmierska1, Tomasz Polawski1, Agnieszka Sobczynska-Tomaszewska7, Kamila Czerska7, Mariusz Oltarzewski1, Ewa Helwich4, and Tomasz Maciejewski2
1Screening and Metabolic Diagnostics Department, Institute of Mother and Child, Warsaw, Poland
2Obstetrics and Gynecology Department , Institute of Mother and Child, Warsaw, Poland
3One Day Hospitalization Unit, Institute Mother and Child, Warsaw, Poland
4Neonatal Pathology Department , Institute of Mother and Child, Warsaw, Poland
5Metabolic Outpatient Clinic, Institute of Mother and Child, Warsaw, Poland
6Neurological Department , Institute of Mother and Child, Warsaw, Poland
7Medgen Medical Center, Warsaw, Poland
420 - D, L-3-Hydroxybutyrate Treatment of HMG-CoA Lyase Deficiency in a Patient
Beena Devanapalli, Shanti Balasubramaniam, and Kevin Carpenter
Sydney Children’s Hospital Network, Westmead, Australia
3-hydroxy-3-methylglutaryl-coenzyme A (HMG CoA) lyase deficiency is a rare inborn error of metabolism characterized by recurrent metabolic crises generally presenting in neonates (30%) or infancy (60%) during catabolic states triggered by prolonged fasting or intercurrent illness. Acute decompensations with lethargy, vomiting, hypotonia, hypoketotic hypoglycemia, and metabolic acidosis may evolve into Reye-like syndrome without treatment, with acute liver failure, hyperammonemic encephalopathy, dilated cardiomyopathy and death in 20% of cases. Long-term health complications include psychomotor retardation, white matter abnormalities, epilepsy, hepatic steatosis, pancreatitis, cardiomyopathy, and arrhythmias. The enzyme catalyzes the cleavage of HMG-CoA to acetyl-CoA and acetoacetate, the common final step of ketogenesis and leucine degradation, resulting in a diagnostic urinary organic acid pattern with absence of ketonuria, elevated 3-hydroxy-3-methylglutaric, 3-methylgutaconic, 3- methylglutaric, and 3-hydroxyisovaleric acids. Definitive diagnosis requires enzyme activity assays and/or genetic testing. Standard treatment includes protein (leucine) and fat restriction, carnitine supplementation, avoidance of fasting, and use of high carbohydrate based caloric intake when unwell. Here, we describe biochemical findings, mutation studies and clinical course in a patient with severe neonatal onset disease presenting with metabolic acidosis, non-ketotic hypoglycemia, hyperammonemia, and white matter changes on brain MRI. In addition to the standard management, D, L-3-hydroxybutyrate was used as an adjunct therapy to prevent potential cerebral dysfunction and cardiomyopathy, with the rationale that decreased ketone bodies (major energy source for the brain and the heart during starvation), synthesis occurs in this disorder. D, L-3-hydroxybutyrate therapy appears safe and effective in minimizing frequency and severity of acute decompensations.
421 - Glutaric Aciduria Type 1 Misdiagnosed as Dystonic Cerebral Palsy
Sarar Mohamed1, Muddathir Hamad2, and Mustafa Salih2
1Prince Sultan Military Medical City, Riyadh, Saudi Arabia
2King Saud University Medical City, Riyadh, Saudi Arabia
422 - Dietary fibers and propionate production in an in vitro gut fermentation system
Mirjam Kuhn-Lemaire1, Sebastian Tims1, Maryam Raksshandehroo1, Guus Roeselers1, and Jan Knol2
1Nutricia Research, Utrecht, the Netherlands
2University Wageningen, Wageningen, the Netherlands
423 - Fumarase Deficiency: A High Fat/Low Carbohydrate Diet is Safe and Potentially Disease Modifying
Bryony Ryder1, Francesca Moore2, John Christodoulou3, and Shanti Balasubramaniam1
1Western Sydney Genetics Program, The Children’s Hospital At Westmead, Sydney, Australia
2New South Wales Biochemical Genetics Service, Sydney, Australia
3Neurodevelopmental Genomics Research Group, Murdoch Children’s Research Institute, Melbourne, Australia
Fumarate hydratase deficiency (FHD), caused by biallelic alterations of the fumarate hydratase (FH) gene, is a rare disorder of the tricarboxylic acid (TCA) cycle. The clinical phenotype is varied, ranging from a fulminant course with progressive infantile encephalopathy, profound psychomotor retardation, refractory seizures, and fatal outcome in early childhood to a less common, milder phenotype with profound speech delay and longer term survival. Severely affected children generally have FH enzyme activity less than 10% of the control mean. There are currently no recognized therapies and only isolated reports of unsuccessful dietary modifications. Herein, we describe the safe and possibly disease modifying effect of a high fat, low carbohydrate diet in a 12-year-old female with FHD. A severe phenotype was predicted based on her presentation by 6 months of age, with failure to thrive, hypotonia, developmental delay, MRI brain abnormalities with cerebral atrophy and polymicrogyria, subsequent seizures and fibroblast enzyme activity 9% of normal controls. Molecular analysis revealed compound heterozygosity for two mutations previously reported in severe cases with early fatality. FH catalyzes the reversible interconversion of fumarate and malate, and its deficiency leads to impaired energy production due to interruption in the flow of the TCA cycle with subsequent accumulation of various TCA intermediates including fumarate, succinate, 2-ketoglutarate and citrate. Each complete beta-oxidation of palmitate generates 8 molecules of acetyl-CoA which subsequently releases 2 molecules of NADH per acetyl-co A molecule fed into the TCA cycle, preceding the fumarate block. As a long chain of reduced carbon atoms, fatty acids fuel more cycles of the TCA cycle than glycolysis, and additionally generate one molecule each of NADH and FADH2, for each cycle of beta-oxidation. Hence, we propose that a high fat diet may increase the amount of reduced high-energy molecules, allowing increased ATP generation through the mitochondrial electron transport chain. Interestingly, we have not observed the expected increase in urinary fumarate levels with this dietary management. Contrary to predictions, her clinical progression has followed a milder phenotype with well-controlled seizures and mild-moderate intellectual disability, possibly due to the novel dietary intervention commenced at 14 months of age.
424 - L-2-Hydroxyglutaric Aciduria Treated With Riboflavin: A Case Report
Julia Valeriano de Almeida, Fernanda Veiga de Goes, Marcela Rodriguez de Freitas, Lúcio José de Santa Ignêz, Paula Silva, Renata Joviano Alvim, Nicolle Motta Barroso, Ludmilla Athayde Antunes Kramberger, Ana Paula Rodrigues Lazzari Amâncio, Alessandra Costa, and Tania Regina Dias Saad Salles
Instituto Fernandes Figueira / Fiocruz, Rio de Janeiro, RJ, Brazil
L-2-Hydroxyglutaric aciduria (L2HGA) is a rare, autosomal recessive, cerebral organic acid disorder with a characteristic disease course. It is a disorder of metabolite repair and presents exclusively neurological symptoms. The deficiency of FAD-linked L-2-hydroxyglutarate dehydrogenase (L2HGDH) leads to accumulation of L-2-hydroxyglutarate in CSF, plasma and urine. Patients exhibit a slowly progressive disease course, with mental and psychomotor delay, accompanied by symptoms such as seizures, cerebellar ataxia, macrocephaly and extrapyramidal, pyramidal or pseudobulbar signs. Brain imaging shows a characteristic pattern of diffuse, mostly subcortical cerebral white matter abnormalities and basal ganglia (especially putamen and globus pallidus) and dentate nuclei abnormalities. The objective of this study is to report a case of L2HGA and review the literature available on the disease and differential diagnoses. The patient was the only son of a consanguineous Brazilian couple and presented at 6 months with generalized tonic-clonic seizures. He had mild developmental delay and macrocephaly. He evolved with poor seizure control and was admitted at 11 months for inpatient treatment, when medication dosage was adjusted and a computerized tomography (CT) scan was obtained, revealing diffuse white matter hypodensity. Magnetic resonance imaging (MRI) of the brain revealed bilateral and symmetrical abnormalities of the basal ganglia (putamen and globus pallidus), the dentate nuclei and the frontal-parietal-temporal-occipital brain white matter, with sparing of the corpus callosum and brain stem. Qualitative mass spectrometry in two urine samples showed elevated levels of 2-hydroxyglutaric acid without other Krebs cycle metabolites. Plasma amino acids analysis was normal. Based on clinical signs, imaging study and laboratory results, he was diagnosed with L2HGA and started on riboflavin 100 mg/day at 18 months. At 3 years old, patient remains stable, with some developmental delay, gaining milestones, with no new symptoms. Fast diagnosis is the key for timely commencement of treatment. Although reports regarding the use of riboflavin on L2HGA are still anecdotal, they suggest that it might slow down disease progression. Although enantiomeric analysis and genetic tests weren’t available in this case, the accumulation of 2-hydroxyglutaric acid in the context of typical clinical and imaging findings allowed for the start of treatment with minimal delay.
425 - A New Case of Molecularly Confirmed Combined Malonic and Methylmalonic Aciduria in Poland
Malgorzata Sredzinska1, Dariusz Rokicki2, Dariusz Kozlowski3, Magdalena Pajdowska3, Anna Bogdanska3, Piotr Buda4, Mikołaj Danko2, Janusz Ksiazyk2, Elzbieta Ciara5, Dorota Piekutowska-Abramczuk5, and Katarzyna Popinska2
11 Department of Pediatrics, Nutrition And Metabolic Disorders, The Children’s Memorial Health Instit, Warsaw, Poland
21 Department of Pediatrics, Nutrition and Metabolic Disorders, Warsaw, Poland
32 Department of Biochemistry, Radioimmunology and Experimental Medicine, Warsaw, Poland
41 Department of Pediatrics, Nutrition and Metabolic Disorders, Warsaw, Poland
53 Department of Medical Genetics, Warsaw, Poland
426 - Severity and Variety of Management in Five Patients With Methylmalonyl-CoA Mutase Deficiency
Tetsuya Ito1, Yoko Nakajima1, Yasuhiro Maeda2, Yoshimi Sakai3, Kana Gotoh2, Tatsuya Suzuki4, Hiroki Kurahashi5, and Tetsushi Yoshikawa1
1Department of Pediatrics, Fujita Health University, Toyoake, Japan
2Graduate School of Pharmaceutical Sciences, Nagoya City University, Nagoya, Japan
3Aichi Health Promotion Public Interest Foundation, Nagoya, Japan
4Department of Pediatric Surgery, Fujita Health University, Toyoake, Japan
5Division of Molecular Genetics, Fujita Health University, Toyoake, Japan
427 - Vitamin B12 Responsive Methylmalonic Acidemia (MMAr): Medical and Dietetic Treatment, Biochemical Profiles, and Outcomes of Patients From a Single Center Cohort
Victoria Hunn1, Rachel Skeath1, Sarah Cawtherley1, Stephanie Grunewald2, Maureen Cleary2, Spyros Batzios2, James Davison2, Paul Gissen2, Mel Mcsweeny2, and Marjorie Dixon1
1Dietetics, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
2Metabolic Medicine, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
428 - Mevalonate Kinase Deficiency Syndrome: A Case Report
Sofía Ortiz Saldaña1, Diana Salazar Bermeo1, Rachel Sayuri Honjo1, Cristina Núñez Vaca1, Débora Romeo Bertola1, Guilherme Lopes Yamamoto1, Santiago Estrella Benavides1, Gustavo Marquezani Spolador1, Antonio Carlos Pastorino2, Mayra de Barros Dorna2, Clóvis Almeida da Silva3, Katia Tomie Kozu3, and Chong Ae Kim1
1Genetics Unit Of Instituto da Criança do Hospital das Clínicas da Universidade de São Paulo, São Paulo, SP, Brazil
2Immunology Unit Of Instituto da Criança do Hospital das Clínicas da Universidade de São Paulo, São Paulo, SP, Brazil
3Rheumatology Unit Of Instituto da Criança do Hospital das Clínicas da Universidade de São Paulo, São Paulo, SP, Brazil
The hyperimmunoglobulinemia D / Mevalonate kinase deficiency (MKD) is a rare autosomal recessive inherited autoinflammatory disease characterized by recurrent fever associated to persistent episodes of hyperinflammation, abdominal pain, arthralgias, and mucocutaneous lesions. It is caused by loss of function mutations in MVK, which encodes for the protein mevalonate kinase. Mevalonate kinase is an essential enzyme in the common pathway leading to both cholesterol and non-sterol isoprenoids, which are necessary for several essential biologic processes. Typically, patients start to show symptoms in the first years of life. As clinical manifestations are unspecific and often mimic a chronic inflammatory disease, the diagnosis is challenging and requires immunologic, genetic, and biochemical investigations. Here we present a 19-year-old male, child of consanguineous parents, with recurrent episodes of fever since he was 2 months old. At three months of age, he presented lymphadenopathy and three months later hepatosplenomegaly. At the age of four, a liver biopsy showed granuloma suggesting mycobacteriosis, however, no mycobacteria were found and tuberculin skin test was negative. He constantly suffered from painful cervical lymphadenopathy, tonsillitis and suppurative otitis, as well of skin lesions. At the age of seven, he was submitted to a diagnostic laparoscopy due to acute abdomen, which led to a final diagnosis of primary peritonitis. Laboratorial tests showed anemia, leukocytosis and elevation of inflammation markers, as well as increased levels of IgA and IgG. He presented normal lymphocyte immunophenotyping and normal myelogram. At the age of 11, after exclusion of several immunodeficiency syndromes, a diagnosis of MKD was suspected. Analysis of the MVK gene confirmed a mutation in homozygosis, and urinary organic acids analysis showed an increased mevalonic acid excretion, confirming the diagnosis of MKD. Patient was first managed with simvastatin, however with poor adherence. After several years of treatment with corticosteroids and antibiotic prophylaxis, he showed an improvement of the autoinflammatory symptomatology. This case illustrates an example of an inborn error of metabolism affecting the cholesterol biosynthesis with an autoinflammatory phenotype, characterized mainly as fever of unknown origin. Determination of mevalonic aciduria may be helpful to support the diagnosis if molecular tests are not available.
429 - L-2-Hydroxyglutaric Aciduria Case Series
Fatma Derya Bulut1, Deniz Kor1, Sebile Kilavuz1, Berna Seker Yilmaz1, Faruk Incecik2, Özlem Hergüner2, Murat Oktem3, Meltem Demirkiran4, Şakir Altunbasak2, and Neslihan Mungan1
1Division of Ped Metabolism, Çukurova University, Adana, Turkey
2Division of Ped Neurology, Çukurova University, Adana, Turkey
3Düzen Laboratories, Ankara, Turkey
4Division of Neurology, Çukurova University, Adana, Turkey
430 - Early Detection, Treatment and Prognosis of Combined Malonic and Methylmalonic Aciduria in a Mexican Newborn: Case Report
Diana Laura Vazquez-Cantu1, Valeria María Gutiérrez-García2, Consuelo Cantú-Reyna1, Héctor Cruz-Camino1, and Adrián Martínez-Canseco1
1Genomi-K S.A.P.I. de C.V., Monterrey, Mexico
2Escuela de Medicina Y Ciencias de La Salud Tecsalud Del Tecnológico de Monterrey, Monterrey, Mexico
Combined Malonic and Methylmalonic Aciduria (CMAMMA) (OMIM #614265) is an autosomal recessive inborn error of metabolism characterized by elevations of urine malonic acid (MA), and methylmalonic acid (MMA), secondary to malonyl-CoA decarboxylase (MCD) deficiency. CMAMMA is claimed to be the most common intracellular disorder of cobalamin metabolism with an incidence of 1/100 000 to 1/37 000 live births worldwide. Patients with CMAMMA have normal development, although they may also have severe complications such as: metabolic acidosis, developmental delay, seizures, cardiomyopathy, gastrointestinal distress, and dysmorphic features. The possibility to improve the prognosis in patients with CMAMMA depends upon the early detection. We present an asymptomatic 1-month-old Mexican female with CMAMMA detected by newborn screening. The quantification of organic acids in urine showed significantly increased levels of methylmalonic acid (1369 mg/dL). The molecular study found a variant within the ACSF3 gene supporting the diagnosis of CMAMMA. The treatment includes adjustments in her diet combining a formula MTVI free (methionine, threonine, valine, and isoleucine) and breast milk, whose content quantities varied upon the follow-up test. We aim to report the followed pathway through a correct diagnosis, the therapeutic strategy and to compare it with the ones reported in literature. Early detection and treatment with parenteral OHCbl have decreased the mortality and reversed the complications in newborns with CMAMMA. Therefore, it is important to make a complete prenatal care, newborn screening, and to raise awareness.
431 - The Clinical, Biochemical Features, and Mutational Analyses in Glutaric Acid Type 1 Patients
Berrak Bilginer Gurbuz1, Yilmaz Yildiz1, Emine Goksoy1, Didem Yucel Yilmaz2, Ali Dursun1, Ayşegül Tokatli1, Turgay Coskun1, Serap Sivri1
1Pediatric Metabolism, Hacettepe University, Ankara, Turkey
2Pediatric Metabolism, Instutite of Pediatrics, Hacettepe University, Ankara - Turkey
432 - Analysis of Urinary Organic Acid Excretion Profile in Children
Janeth Parra, Angie Calvo, Stefany Casallas, Olga Echeverri, and Johana Guevara
Institute for the Study of Iem (Ieim), Pontificia Universidad Javeriana, Bogotá, Colombia
433 - Analysis of Urinary Organic Acid Excretion Profile in Newborns Feed With Infantile Formulas
Angie Calvo, Stefany Casallas, Janeth Parra, Johana Guevara, and Olga Echeverri
Institute for the Study of Iem (Ieim), Pontificia Universidad Javeriana, Bogotá, Colombia
434 - Glutaric Aciduria Type 1: Twenty-Four Cases in Brazil Over a Ten-Year Period Experience
Eduardo Vieira Neto1, Luiz Nelson Lopes Ferreira Gomes2, Armando Fonseca2, and Jacqueline Harouche Rodrigues da Fonseca2
1Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
2Laboratório Diagnósticos Laboratoriais Especializados, Rio de Janeiro, RJ, Brazil
435 - Completing the Metabolic Network Around 2-Hydroxyglutarate
Nicole Paczia, Julia Becker, Paul Jung, Dean Cheung, and Carole Linster
Luxembourg Center For Systems Biomedicine, Belvaux, Luxembourg
2-Hydroxyglutarate (2HG) is an atypical metabolite that accumulates in neurometabolic diseases as well as in certain types of cancer. The mechanisms through which 2HG leads to cell transformation or neurodegeneration remain, however, poorly understood. Compared to the research on 2HG in mammalian systems, and despite certain advantages of yeast as a model organism for biomedical research, only a very limited number of studies reported on the occurrence and metabolism of 2HG in yeast. An extensive study performed over the last two years in our lab, revealed a panoply of new findings on 2HG metabolism of Saccharomyces cerevisiae. Among those the fact that the yeast phosphoglycerate dehydrogenases Ser3 and Ser33 convert α-ketoglutarate to D-2HG in addition to their primary metabolic role, which consists in catalyzing the first step of the serine synthesis way converting 3-phosphoglycerate to 3-phosphohydroxypyruvate. Our results also show, however, that the two identified D-2HG producing enzymes do not represent the only sources of this metabolite in yeast. Within our pilot study, the two dehydrogenases Dld2 and Dld3 were both shown to convert D-2HG to α-ketoglutarate in vitro and the purified recombinant enzymes were found to have a higher affinity for D-2HG than for D-lactate. Targeted metabolome analyses and biochemical characterization led additionally to the original finding that DLD3 is actually an FAD-dependent transhydrogenase that converts D-2HG to α-ketoglutarate, using pyruvate as a hydrogen acceptor. Based on our findings, we were for the first time able to propose a central carbon network of Saccharomyces cerevisiae integrating the metabolite D-2HG and connecting its metabolism to the mitochondrial respiratory chain (1). In the present research project, we aimed to further elucidate the metabolic network involved in 2HG formation and degradation in yeast as well as to gain a better understanding of the cell functions that are impacted by pathological intracellular 2HG concentrations. Using targeted metabolome analysis and high-throughput growth phenotyping, we analyzed the accumulation of D-2HG in natural yeast isolates. Applying the same methodologies on strains lacking genes known to be involved in the metabolism of 2HG in yeast, we compared the effect of 2HG accumulation under various metabolic states of the cell.
436 - Effect of EPI-743 on the Clinical Course of Visual Damage in Cobalamin C Patients: A Prospective Randomized Double-Blind Phase II Clinical Trial
Diego Martinelli1, Daria Diodato1, Daniela Ricci2, Benedetto Falsini3, Giancarlo Iarossi4, Giorgia Olivieri1, Ferdinando Ceravolo1, Maria Luigia Gambardella2, Gloria Ferrantini2, Eugenio Mercuri2, and Carlo Dionisi Vici1
1Division of Metabolism, Bambino Gesu’ Children’s Hospital, Rome, Italy
2Department of Child Neurology, Catholic University of Sacro Cuore, Rome, Italy
3Institute of Ophthalmology, Catholic University of Sacro Cuore, Rome, Italy
4Division of Ophthalmology, Bambino Gesu’ Children’s Hospital, Rome, Italy
437 - Glutaric Aciduria Type I Diagnosis Case With Normal Glutaryl Carnitine and Urine Organic Acid Analysis
Ebru Canda1, Havva Yazici1, Esra Ben1, Cenk Eraslan2, Yasemin Atik Altinok1, Mine Serin3, Sara Habif4, Gul Aktan Serdaroglu3, Sema Kalkan Uçar1, Huseyin Onay5, Ferda Ozkinay5, Mahmut Çoker1
1Pediatric Metabolism and Nutrition, Ege University Faculty of Medicine, Izmir, Turkey
2Department of Radiology, Ege University Faculty of Medicine, Izmir, Turkey
3Pediatric Neurology, Ege University Faculty of Medicine, Izmir, Turkey
4Department of Biochemistry, Ege University Faculty of Medicine, Izmir, Turkey
5Department of Genetics, Ege University Faculty of Medicine, Izmir, Turkey
Glutaric aciduria type I (GAI) is a rare inherited metabolic disease, deficiency of glutaryl-CoA dehydrogenase results in accumulation of the putatively neurotoxic metabolites glutaric and 3-hydroxyglutaric acid (GA, 3-OH-GA) in body tissues, particularly within the brain. Here we presented a 3-year-old girl with hypotonia and dystonia diagnosed with GAI although the repeated analysis of the carnitine profile and organic acid analyzes were normal. The patient has motor, mental retardation, and hypotonia. Her weight was on 3-10 percentile, height on 25-50 percentile, and head circumference on 25 percentile at the age of 3 years. The physical examination was normal except severe hypotonia. Spot blood carnitine profile, blood amino acid, urine organic acid, lactic acid and pyruvic acid were normal in repeated analyzes. Dystonia and spastic tetraparesia developed on her follow-up. Cranial MR scan revealed bilateral striatal necrosis. In GCDH gene analysis, p. Y123C (c.368A> G) /p.L340F (c.368A> G) mutation was found. There was no history of encephalopathy. The patient treated with levodopa and trihexepenidil and lysine-restricted diet. In the presence of bilateral striatal necrosis and dystonia, glutaric aciduria type I should be kept in mind. Blood carnitine profile and urine organic acid analyzes may not be consistent. It is important to evaluate the cases for genetic investigation.
438 - Overview of Organic Acidemia Diagnosis and Other Inborn Errors of Metabolism from a Reference Center in Chile
Karen Fuenzalida, Jorge Lobos, Katerina Betta, and Juan Francisco Cabello
Inta-Uchile, Santiago, Chile
439 - Impaired Bone Health in Methylmalonic Acidemia and Propionic Acidemia: An Underrecognized Comorbidity
Oluwakemi Ogunmoye, Mel Mcsweeney, Spyros Batzios, Maureen Cleary, and Stephanie Grunewald
Great Ormond Street Hospital, London, United Kingdom
440 - Neuroradiological Findings in Glutaric Aciduria Type 1 a Key for Diagnosis
Carolina Arias, Juan Francisco Cabello, Pilar Peredo, Castro Chaves, Valerie Hamilton, Veronica Cornejo, Alf Valiente, Karen Fuenzalida, Alicia de La Parra, and Maria Ignacia Garcia
Institute of Nutrition and Food Technology (Inta), University of Chile, Santiago, Chile
M) Carbohydrate Disorders (441 to 473)
441 - Normalization of Cardiomyopathy and Clinical Improvement on Ketogenic Diet in Patient With GSD Type IIIA
Urh Groselj, Helena Kobe, Mojca Zerjav Tansek, Andreja Sirca Campa, and Tadej Battelino
University Children’s Hospital, Umc Ljubljana, Ljubljana, Slovenia
442 - Familial Glycogen Storage Disease Type IX Diagnosed by Targeted Exome Sequencing
Young Bae Sohn1, Ju Young Jang1, Dakeun Lee1, and Ja-Hyun Jang2
1Ajou University Hospital, Ajou University School of Medicine, Suwon, South Korea
2Green Cross Genome, Yongin, South Korea
Glycogen storage disease type IX (GSD IX) is caused by deficiency of phosphorylase kinase which plays a role in breakdown of glycogen. Mutations in the PHKA2 are the most common cause of GSD IX. Clinical manifestations of X-linked recessive GSD IX resulting from PHKA2 mutation include hepatomegaly, growth retardation, fasting hypoglycemia, and fasting ketosis. However, the symptoms overlap with those of other types of GSDs. Here, we report Korean familial cases with GSD IX whose diagnosis was confirmed by targeted exome sequencing. A 4-year-old male patient was presented with hepatomegaly and persistently elevated AST/ALT. Liver biopsy revealed swollen hepatocyte filled with glycogen storage, suggesting GSDs. Targeted exome sequencing was performed for the differential molecular diagnosis of various types of GSDs. A hemizygous mutation in PHKA2 were detected by targeted exome sequencing and confirmed by Sanger sequencing: c.3632C>T (p.Thr121Met), which was previously reported. The familial genetic analysis revealed that his mother was heterozygous carrier of c.3632C>T mutation and his 28-month old brother had hemizygous mutation. His brother also had hepatomegaly and elevated AST/ALT. The hypoglycemia was prevented by frequent meals with complex carbohydrate, as well as cornstarch supplements. Their growth and development is in normal range. We suggest that targeted exome sequencing could be a useful diagnostic tool for the genetically heterogeneous and clinically indistinguishable GSDs. A precise molecular diagnosis of GSD can provide appropriate therapy and genetic counseling for the family.
443 - Challenges in Monitoring Siblings With Glycogen Storage Disease in a Rural Area
Moretta Damayanti, Nice Rachmawati, and Damayanti Rusli Sjarif
University of Indonesia, Jakarta, Indonesia
444 - A rare cause of isolated hepatomegaly: Glycogen-storage disease type VI
Sevil Dorum, Sahin Erdol, and Halil Saglam
Uludag University Faculty of Medicine, Bursa, Turkey
445 - Endogenous Synthesis of Galactose in Galactosemics With Galactose Restricted Diet
Umair Mahmood1, Pervez Akhtar1, Huma Arshad Cheema2, Shahid Ur Rehman Mahmood1, and Saqib Mahmood3
1University of Agriculture Faisalabad, Sub Campus Toba Tek Singh, Toba Tek Singh, Pakistan
2The Children’s Hospital and Institute of Child Health, Lahore, Pakistan
3University of Health Sciences, Lahore, Pakistan
446 - Fructose 1,6 Bisphosphatase Deficiency: An Important Cause of Hypoglycemia in Children
Sarar Mohamed, Rihab Salih, Amal Alhashem, and Aida Alaqeel
Prince Sultan Military Medical City, Riyadh, Saudi Arabia
447 - Evaluation of Clinical and Genetic Findings of Patients With Galactosemia
Pelin Teke Kisa1, Engin Kose1, Ozlem Unal2, Melis Kose3, Burcu Ozturk Hismi4, Selda Bülbül5, Mehmet Gunduz2, Aynur Kucukcongar Yavas2, and Nur Arslan1
1Division of Pediatric Metabolism and Nutrition, Dokuz Eylul University Faculty of Medicine, İzmir, Turkey
2Division of Pediatric Metabolism and Nutrition, Ankara Children's Education and Research Hospital, Ankara, Turkey
3Division of Pediatric Metabolism and Nutrition, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
4Division of Pediatric Metabolism and Nutrition, Tepecik Training and Research Hospital, İzmir, Turkey
5Division of Pediatric Metabolism and Nutrition, Kirikkale University, Kirikkale, Turkey
448 - Plasma Deoxysphingolipids as Potential Novel Biomarkers in Glycogen Storage Disease Type 1
Michel Hochuli1, Matthias Gautschi2, Emanuel Christ2, Fabian Meienberg3, Stefan Bilz4, Matthias Baumgartner5, and Thorsten Hornemann1
1University Hospital Zurich, Zurich, Switzerland
2University Hospital of Bern, Inselspital, Bern, Switzerland
3University Hospital Basel, Basel, Switzerland
4Kantonsspital St. Gallen, St. Gallen, Switzerland
5University Children’s Hospital, Zurich, Switzerland
449 - Prevalence of Nonalcoholic Fatty Liver Disease in Fructosemia Patients
Luis Aldámiz-Echevarria1, Rafael Suárez Del Villar2, Maria Luz Couce3, Carlos Alcalde4, Mónica Ruiz5, Javier de Las Heras2, and Fernando Andrade1
1Biocruces Health Research Institute, Barakaldo, Spain
2Cruces University Hospital, Barakaldo, Spain
3Santiago de Compostela University Hospital, Santiago, Spain
4Río Hortega University Hospital, Valladolid, Spain
5Nuestra Señora de La Candelaria University Hospital, Tenerife, Spain
450 - Congenit Hyperinsulinism With Response to Diazoxide
Nelsy Loango Chamorro, Patricia Landazuri, Beatriz Restrepo Cortés, and Marcela Fama
Universidad Del Quindio, Armenia, Colombia
451 - Successful use of Diazoxide on Glucose Homeostasis in Three Patients With Glycogen Storage Disease Type Ia
Nathan Giroux1, François Feillet1, Claire Bansept1, Elise Jeannesson1, Chloé Guinet-Charpentier1, Emeline Renard1, Arnaud Wiedemann1, Floriane Sifaoui1, Laurent Bonnemains2, and Chrystele Bonnemains1
1Reference Center for Inborn Errors of Metabolism, Children University Hospital of Nancy, Nancy, France
2Inserm U947, Children University Hospital of Nancy, Nancy, France
Main treatment in glycogen storage disease type I (GSD I), caused by glucose-6-phosphatase deficiency, is based on appropriate carbohydrate intake with frequent meals and continuous night feeding via nasogastric tube to avoid hypoglycemia and further complications. Diazoxide, a non-diuretic benzothiadiazine drug, was first used in 1968 by Rennert and Mukhopadhyay with an improvement of the glucose homeostasis in two sibs with GSD I. Since then, to the best of our knowledge, the use of diazoxide in order to obtain a good metabolic control has not been reported again. We describe three young patients with GSD I treated by diazoxide (dose from 10 to 15 mg/kg per day). Diazoxide was introduced because of poor metabolic control with recurrent hypoglycemia despite constant increase of carbohydrate intake, suggesting functional hyperinsulinism. Age at introduction of diazoxide was 9-month-old for patient 1, 10-month-old for patient 2, and 21-month-old for patient 3 and treatment duration was 12 months, 6 years, and 10 months, respectively. The treatment was well tolerated and hypoglycemic events decreased (P < .05 in all patients) whereas daily carbohydrate intake was reduced (P < .05 in all patients) without reoccurrence of hypoglycemia. Mean blood lactate concentrations decreased by 36% in the first patient (from 6.5 to 4.2 mmol/L; P = .025), by 47% in the second patient (from 7.5 to 4 mmol/L; P < .001) and by 26% in the third patient (from 4.3 to 3.2 mmol/L; P = .003). Diazoxide treatment, in addition to nutrition regimen, helped to counteract the functional hyperinsulinism. Decreasing the number of hypoglycemia with diazoxide resulted in lower carbohydrate intake requirement to maintain normoglycemia, setting a better metabolic control which may be protective against the risk of adenomas development.
452 - Overweight and Obesity Prevalence in Children With Glycogen Storage Disease From a Single UK Center
Joanna Gribben1, Kate Billmore1, Carla Fitzachary1, Arlene Slabbert1, and Helen Mundy2
1Nutrition & Dietetic Dept, Guy’s & St Thomas’ NHS Foundation Trust, London, United Kingdom
2Centre for Inherited Metabolic Disease, Evelina London, Guy’s & St. Thomas’ Nhs Foundation Trust, London, United Kingdom
453 - A Change in Practice: Home Ketone Monitoring in Glycogen Storage Disorders (GSD) 0, III, VI, and IX
Tanya Gill1, Jane Gick1, Gemma Hack1, Joanna Gribben2, Kate Billmore2, Zehra Arkir3, and Helen Mundy1
1Centre for Inherited Metabolic Diseases, Evelina London Children’s Hospital, Guy’s & St. Thomas’ NHS, London, United Kingdom
2Nutrition & Dietetic Dept, Guys & St Thomas’ NHS Foundation Trust, London, United Kingdom, London, United Kingdom
3Biochemical Sciences, Guy’s & St. Thomas’ NHS Foundation Trust, London, London, United Kingdom
454 - Evaluation of the Thyroid Hormone Receptor Agonist VK2809 in an In Vivo Model of Glycogen Storage Disease Type Ia
Lauren Waskowicz1, Dwight Koeberl1, Brian Lian2, Hiroko Masamune2, and Geoff Barker2
1Duke University, Durham, NC, USA
2Viking Therapeutics, San Diego, CA, USA
455 - Stimulation of Autophagy With Bezafibrate Reverses Hepatic Steatosis in Glycogen Storage Disease Ia
Lauren Waskowicz1, Zhou Jin2, Songtao Li1, Paul Yen2, and Dwight Koeberl1
1Duke University, Durham, NC, USA
2National University of Singapore, Singapore, Singapore
456 - A Case Report of the Primary Caregivers’ Experience of Diet Therapy of Children With Hepatic Glycogen Storage Diseases in Japan
Keiko Yamaguchi1, Mika Ishige2, Erika Ogawa3, and Tomoka Takano3
1University of Tsukuba, Ibaraki, Japan
2Nihon University School of Medicine, Tokyo, Japan
3Nihon University Hospital, Tokyo, Japan
457 - Hepatic Glycogenoses Among Children and Adolescents—Developing Country Perspective
Sophy Korula and Anna Simon
Christian Medical College and Hospital, Vellore, Tamil Nadu, India
458 - High Frequency of Glycogen Storage Disease Type IX in Cohort of Russian Patients With Liver Glycogen Storage Diseases
Elena Kamenets1, Madlena Bagaeva2, Madlena Bagaeva2, Andrey Zubovich2, Yulia Itkis1, Natalia Milovanova1, Ilya Nagornov1, Maria Melikian3, and Ekaterina Zacharova1
1Fsbi «Research Centre for Medical Genetics», Moscow, Russia
2Fsbis «Federal Research Centre for Nutrition and Biotechnology», Moscow, Russia
3Fsbi «Research Centre for Endocrinology», Moscow, Russia
459 - Homozygous c.966C>A p.(Phe322Leu) Change in the G6PC Gene in a Patient With Mild Glycogen Storage Disease 1a
Carol Hardy1, Adam Gerrard1, Piers Fulton1, Tim Hutchin1, Raph Wigley2, Susan Beath1, Saikat Santra1, Thalia Antoniadi1, and Mary Anne Preece1
1Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, United Kingdom
2Great Ormond Street Hospital NHS Foundation Trust, London, United Kingdom
We present a patient with a complex clinical history where molecular testing identified a likely pathogenic variant of the G6PC gene, but biochemical and enzyme analysis suggested an atypical presentation of glycogen storage disease type Ia. The child was born at term after a concealed pregnancy. There were respiratory problems from birth, swallowing difficulties, failure to thrive, and developmental delay. He was on continuous tube feeds overnight from an early age. Dysmorphic features in infancy were investigated by chromosome and array CGH analysis with no abnormality detected. Metabolic investigations with normal results included urine organic acids, acyl carnitines, chitotriosidase, and lysosomal enzymes. At 5 years of age, he presented with an enlarged liver but normal liver function tests which became abnormal by age 8. Plasma cholesterol and triglycerides were increased. Uric acid was normal. He was fasted for a liver biopsy and became hypoglycemic. A 12- hour fast did not show hypoglycemia, although lactate was consistently but mildly elevated. Next-generation sequencing of 27 genes associated with glycogen storage disease and related disorders was performed using the Illumina TruSight ONETM sequencing panel kit and a HiSeq (Illumina) analyzer. Analysis of genes of interest was performed using an in-house pipeline. Two variants of interest were identified: an apparently homozygous missense change in the G6PC gene, c.966C>A p.(Phe322Leu), and a heterozygous splice site variant in the GBE1 gene (c.691+2T>C). The G6PC variant had been documented in the literature in the heterozygous state (the second mutation was not specified) in a single patient with complete deficiency of hepatic glucose-6-phosphatase. Another study indicates that p.Phe322Leu affects a residue within a transmembrane helix, not the catalytic domain, an in vitro assay showed decreased but not completely absent activity. Glucose-6-phosphatase activity in a liver biopsy from our patient showed an activity of 29 µmol/min/g protein (34-166) with marker enzyme within the normal range. Our patient is unusual in that he has low but not complete absence of G6PC activity invariably seen in GSDIa, suggesting an atypical or mild form of disease may be associated with the p.(Phe322Leu) variant.
460 - Evaluation of Our Patients With Fanconi Bickel Syndrome
Ebru Canda1, Havva Yazici1, Yasemin Atik Altinok1, Sema Kalkan Uçar1, Huseyin Onay2, Ferda Ozkinay2, and Mahmut Çoker1
1Pediatric Metabolism and Nutrition, Ege University Faculty of Medicine, Izmir, Turkey
2Department of Genetics, Ege University Faculty of Medicine, Izmir, Turkey
Fanconi-Bickel syndrome is a rare autosomal recessive disorder due to mutations in the facilitative glucose transporter 2 (GLUT2 or SLC2A2) gene resulting in excessive glycogen storage predominantly in the liver and kidney. The patients with Fanconi-Bickel syndrome were presented to be evaluated with clinical, laboratory and follow-up findings. Four female patients with Fanconi Bickel syndrome were evaluated. Hepatomegaly, hypoglycemia, and tubular dysfunction were detected in all of the patients. The age range of the patients at diagnosis was between 30 months and 7 years of age. Four of them have failure to thrive and initial high SDS scores were −3.03/−3.47/−3.6, and −5.3, respectively. Clinical and laboratory findings of the rickets were also detected. Liver biopsy performed in two patients and liver fibrosis and bridging necrosis, glycogen storage and steatosis were detected. For preventing hypoglycemia all of them treated with uncooked cornstarch and avoid fasting. SLC2A2 gene analysis revealed homozygous p.G162Rfs*17(c.482dupC) mutation in one patient and homozygous p.S169*(c.506C>G) in the other patient. Two of the patients have the same homozygous p.V106X(c.135_322delinsGT) mutation. One of the patients had growth hormone replacement therapy and her final height was 154 cm. In the presence of Fanconi type nephropathy, hepatomegaly, hypoglycemia, Fanconi-Bickel syndrome should be considered in differential diagnosis. Rarely, hypergalactosemia can lead to confusion in the neonatal scan. A similar increase in galactose was detected in one of our patient. Our patients were presented for the rare occurrence and discussion of follow-up data.
461 - Familial Analysis of Clinical Consequences of Galactosemia
Umair Mahmood1, Pervez Akhtar1, Huma Arshad Cheema2, Saqib Mahmood3, Umar Farooq1, Shahid Ur Rehman Mahmood1, and Shazia Bukhari4
1University of Agriculture Faisalabad, Sub Campus Toba Tek Singh, Toba Tek Singh, Pakistan
2The Children’s Hospital and Institute of Child Health, Lahore, Pakistan
3University of Health Sciences, Lahore, Pakistan
4Gc University Faisalabad, Faisalabad, Pakistan
462 - Fructose 1-6 Bisphosphatase Deficiency in Three Turkish Infants
Mustafa Kiliç1, Cigdem Seher Kasapkara1, and Koksal Ozgul2
1Sami Ulus Children Hosp., Metabolism Unit, Ankara, Turkey
2Hacettepe University, Children Hosp., Metabolism Unit, Ankara, Turkey
463 - Long Term Outcome of Patients With Medically Treated Congenital Hyperinsulinism: Subtotal Pancreatectomy Still Needed?
Jean-Baptiste Arnoux1, Céline Roda1, Cécile Saint-Martin2, Christine Bellanne-Chantelot2, and Pascale de Lonlay3
1Necker Enfants Malades Hospital, Aphp, Paris, France
2Pitié Salpétrière Hospital, Aphp, Upmc, Paris, France
3Descartes University, Paris, France
464 - Presence of Two Homozygous Variants for Fructose Intolerance and Deficiency in Whole Exome Sequencing
Tatiana Almeida1, Armando Fonseca2, Claudio Schmidt3, and Jacqueline Harouche Rodrigues da Fonseca2
1Laboratório Dle, São Paulo, SP, Brazil
2Laboratório Dle, Rio de Janeiro, RJ, Brazil
3Centro de Genética Médica do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
465 - Liver Organoids as a Patient-Specific Model to Study Disorders in Energy Metabolism
Imre Schene1, Peter Van Hasselt1, Gepke Visser1, Rúben Ramos2, Hans Clevers3, Edward Nieuwenhuis4, and Sabine Fuchs1
1Department of Metabolic Diseases, Wilhelmina Children’s Hospital, Umc Utrecht, Utrecht, the Netherlands
2Laboratory of Metabolic Diseases, Wilhelmina Children’s Hospital, Umc Utrecht, Utrecht, the Netherlands
3Hubrecht Institute-Knaw, Umc Utrecht, Utrecht, the Netherlands
4Division of Pediatric Gastroenterology, Wilhelmina Children’s Hospital, Umc Utrecht, Utrecht, the Netherlands
466 - Coincidence of Hereditary Fructose Intolerance and Wilms Tumor
Mustafa Kiliç
Sami Ulus Children Hosp., Metabolism Unit, Ankara, Turkey
467 - The Present and Future of Transaldolase Deficiency Based on the Experience From a French Cohort Study and the Literature
François-Xavier Mauvais1, Coraline Grisel1, Dalila Habes2, Anaïs Brassier1, Jean-Baptiste Arnoux1, Chris Ottolenghi3, Emmanuel Gonzales2, Florence Lacaille4, and Pascale de Lonlay1
1Metabolic Diseases Unit / Necker-Enfants Malades Hospital, Paris, France
2Pediatric Hepatology And Liver Transplantation Unit / Bicêtre Hospital, Le Kremlin Bicêtre, France
3Metabolic Biochemistry Lab / Necker-Enfants Malades Hospital, Paris, France
4Pediatric Gastroenterology-Hepatology-Nutrition Unit / Necker-Enfants Malades Hospital, Paris, France
468 - Retrospective Study in Glycogen Storage Disease Type I (GSD I): A Cohort From Garrahan Hospital
Veronica Bindi and Hernan Eiroa
Garrahan Hospital, Buenos Aires, Argentina
469 - Classical Galactosaemia is Associated With Decreased Bone Mineral Density (BMD) in Both Males and Females
Sirisha Penumatsa1, Stephanie Grunewald1, Caroline Brain1, Aisling Oslizlok1, Elaine Murphy2, Mfon Ewang2, and Maureen Cleary1
1Great Ormond Street Hospital, London, United Kingdom
2University College London, London, United Kingdom
470 - Diagnosis and Management of Fructosemia in an Infant—A Case Report
Alessandra Braga, Nathalia Fernandes, Tamires Camargo, Viviane Santos, Lilian Licurgo, Julia Albuquerque, Luisa Simonsen, Monica Moretzsohn, and Hélio Rocha
Ippmg Ufrj, Rio de Janeiro, RJ, Brazil
Fructosemia—also known as hereditary fructose intolerance—is a rare inborn error of fructose metabolism inherited as autosomal recessive disorder due to a deficiency of fructose-1-phosphate aldolase activity resulting in the accumulation of fructose-1-phosphate in the liver, kidneys, and small intestine. Current diagnostic methods for this disease include the fructose tolerance test that measures clinical symptoms upon intravenous fructose challenge and direct assay of aldolase activity in liver biopsy samples. These tests are relatively invasive and not routinely available. A direct DNA analysis that scans for known and unknown mutations has also been reported. This case report is about a 5-year-old child born from a consanguineous marriage that presented multiple episodes of reduced fasting plasma glucose, vomiting, elevated rates on liver enzymes assays and absence of glycosuria since complementary feeding. From the beginning, he was treated as glucogenosis with supplementation of carnitine, B complex, acid folic and administration of cornstarch three times a day. Through his first 3 years he had a few episodes of acute decompensation. His total serum protein, serum alkaline phosphatase, serum gamma GT, coagulation profile, and glycosylated hemoglobin were normal. Ultrasonography of the abdomen revealed mild hepatomegaly without splenomegaly. Gas-chromatographic-mass spectroscopy of urine showed high titles of lactate acid and 3-hydroxibutiric acid. Liver biopsy showed steatosis and intranodular fibrosis. Genetic testing was evaluated and revealed homozygous for fructose 1-6-biphosphate deficiency. Special advice on dietary restrictions on fructose, sucrose and sorbitol was given to the patient and his family. From then on, it was initiated the supplementation of vitamin C and restriction of fructose (fruits, sugars, yogurts, and biscuits) with a good response. Differential diagnosis from galactosemia and tyrosinemia is as important as the histological features may resemble each other. Even in undiagnosed pediatric patients’ recurrent inadvertent fructose ingestion exposes them to the risk of hepatic failure.
471 - Allogeneic Bone Marrow Transplant as Treatment of Triosephosphate Isomerase Deficiency: First Case From the United Arab Emirates
Amal Al Tenaiji1, Nuha Al Zaabi2, and Fatma Al Jasmi3
1Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
2Tawam Hospital, Al Ain, United Arab Emirates
3United Arab Emirates University, Al Ain, United Arab Emirates
Triosephosphate isomerase (TPI, E.C.5.3.1.1) deficiency is an autosomal recessive multisystem disorder presenting with chronic hemolytic anemia and progressive neuromuscular impairment. To date, most cases are fatal in early childhood as there is no available treatment. We describe two cases, female siblings of Emirati origin, currently 3 years and 19 months, respectively, born from consanguineous parents, with genetically confirmed TPI deficiency. Both are homozygous for the c.315G>C variant in the TPI gene. They both presented in the neonatal period with hemolytic anemia requiring frequent blood transfusions. Subsequently, the older sibling had developmental regression at the age of 14 months. She continued to progressively deteriorate neurologically and is currently tracheostomized and ventilator dependent. Both continue to have hemolytic anemia necessitating blood transfusions. However, the younger sibling has only mild hypotonia and developmental delay and therefore her neurological disease has not evolved. Previously, red blood cell transfusion proved to successfully yet transiently increase TPI enzyme activity and reduce DHAP concentration in-vivo in one severely affected patient. In addition to proving the feasibility of increasing TPI enzyme activity, it also suggested that sustained levels are required to achieve continuous delivery of the active enzyme. Additionally, in-vitro studies demonstrated similar results. Therefore, allogeneic bone marrow transplant has been proposed as a means of sustained delivery of functional enzyme in vivo and therefore a potential treatment for TPI deficiency. Our younger patient, was considered a good candidate for bone marrow transplantation as a means of treatment that will deliver functional enzyme continuously and halt the neurological progression as well as normalize the hematological parameters.
472 - Glycogen Storage Disease Patients’ Adherence to Treatment Followed in a Service of Excellence in Inborn Errors of Metabolism
Claudio Magalhaes Dacier Lobato1, Carolina da Cunha Campos Magalhães1, Lília Farret Refosco2, Ida Vanessa D. Schwartz Schwartz2, and Carolina Souza2
1Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
2Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
473 - Clinical and Laboratory Profile of GSD Patients in a Reference Center of Northeast of Brazil
Ney Boa Sorte1, Danilo Ricardo Carneiro Borges2, Tarcisio Costa1, Maria Efigênia Leite1, and Cibele Marques3
1Fima Lifshitz Metabolic Unit / Federal University Of Bahia, Salvador, BA, Brazil
2Universidade do Estado da Bahia, Salvador, BA, Brazil
3Service Of Pediatric Hepatology / Federal University Of Bahia, Salvador, BA, Brazil
Glycogen storage diseases (GSD) comprise a group of disorders that involve the disruption of metabolism of glycogen. Clinical and laboratorial characteristics included failure-to-thrive, hepatomegaly, dolls face, hypoglycemia, dyslipidemia, elevated hepatic transaminases, hyperuricemia and hyperlactatemia. Skeletal and cardiac muscle, the kidneys and liver can be affected.
N) Disorders of Fatty Acid Oxidation and Ketone Body Metabolism (474 to 519)
474 - Lipoic Acid Alleviates the Pathophysiology in Medium-Chain acyl-CoA Dehydrogenase Deficiency
Zahra Nochi1, Rune Isak Dupont Birkler1, Paula Fernandez-Guerra1, Rikke Katrine Jentoft Olsen1, Flemming Wibrand2, Jakob Hansen3, Thomas Juhl Corydon4, and Niels Gregersen1
1Research Unit for Molecular Medicine, Department of Clinical Medicine, Aarhus University Hospital, Aarhus N, Denmark
2Department of Clinical Genetics, Rigshospitalet, Copenhagen, Denmark
3Department of Forensic Medicine, Aarhus University, Aarhus N, Denmark
4Department of Biomedicine, Aarhus University, Aarhus N, Denmark
Medium-chain acyl-CoA dehydrogenase (MCAD) deficiency (MCADD) is the most frequent fatty acid oxidation (FAO) defect in humans. Fibroblasts from MCAD deficient patients have been shown to be more resistant to oxidative stress induced cell death than other FAO defects. The enzymatic defect results in accumulation of octanoic acid, the precursor of lipoic acid (LA). LA is an essential cofactor of the acyltransferase components (E2 s) of α-ketoacid dehydrogenase complexes, comprising pyruvate dehydrogenase (PDC), α-ketoglutarate dehydrogenase (KGDC), and branched-chain α-ketoacid dehydrogenase (BCKDC) multi-enzyme complexes. LA and its reduced form dehydrolipoic acid (DHLA) have a key role in the antioxidant network; they can scavenge various reactive oxygen species (ROS), reduce lipid peroxidation (LPO), chelate heavy metals, and recharge other cellular antioxidant pools, such as vitamins C and E. We hypothesized that LA increases and plays a protective role as an antioxidant in MCADD. To test this hypothesis, the total and lipoylated protein content of LA-dependent enzymes, the level of mitochondrial superoxide, LPO, and manganese superoxide dismutase (MnSOD) were monitored in fibroblasts from MCAD deficient patients and healthy controls. MCAD deficient patient fibroblasts displayed significantly increased PDC-E2 and lipoylated-PDC-E2 protein levels compared to fibroblasts from the control group, whereas the E2 subunits of both KGDC and BCKDC complexes showed no significant difference of protein content. Furthermore, we showed that lipids are less oxidatively damaged in MCAD deficient patient fibroblasts, while higher amounts of mitochondrial superoxide and MnSOD were detected compared to healthy controls. The results suggest that accumulated octanoic acid in MCADD increases the level of LA, keeping the PDC-E2 at an increased steady-state level, to facilitate more synthesis of acetyl-CoA, and thus alleviating the bottleneck in FAO. Additionally, LA may play a role as an antioxidant, and decreasing the level of LPO in MCADD.
475 - Severe Cardiomyopathy in a Child With Vlcad Deficiency Despite Triheptanoin therapy
Alvaro Serrano Russi
Children’s Hospital Los Angeles, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
Patient AJ was born to consanguineous parents of middle eastern origin. Newborn screening collected at five days of life showed a C14:1 acylcarnitine of 3.930 µM (<0.8 µM). ACADVL gene testing showed a homozygous intronic sequence change denominated c.1183-15A>G. She was started on MCT oil and levocarnitine supplementation and was followed over time by cardiology. At 4 years of age she was found to have a severe decrease of her ejection fraction from 40% to 22%. She was admitted with symptoms of congestive heart failure and was switched to Triheptanoin 4 grams/kg/day. There was clinical improvement but her function started to deteriorate further over time. Six months after starting triheptanoin she was admitted to the intensive care unit with severely depressed left ventricular function (EF: 18.1%). Evaluation of previously obtained acylcarnitine profiles showed markedly elevated sums of long chain acylcarnitines (C14+C14:1+C14:2+C16+C18) with elevated free carnitine levels. Patient required intravenous pressors and diuretics and was discharged two months later. Essential fatty acid deficiency was addressed and levocarnitine supplementation was suspended resulting in a decreased sum of long chain acylcarnitines. She was noted to have severe speech delay and perseverant behaviors at the age of 4. A chromosome microarray was requested finding a 128 Mb region of homozygosity across multiple chromosomes and a 751 kb duplication at Xp22.33 involving the genes CRLF2 and CSF2RA which did not correspond to a pathological copy number alteration. A comprehensive cardiomyopathy panel consisting of 75 genes showed a mutation in the gene DSG2 denominated c.91delA (p.T31QfsX14) associated with arrythmogenic ventricular dysplasia. Further studies showed her cardiovascular phenotype was not associated with ARVD. Cardiology has not considered her to be a candidate for heart transplant due to the possible underlying secondary condition. No in vitro studies or exome sequencing have been completed. She is currently ambulatory and stable medically. Echo on March 2017 with EF: 34%. It is not known if the accumulation of long chain acylcarnitines associated with excessive supplementation could have been associated with the poor clinical course. This is a particularly severe case that illustrates the need to follow plasma carnitines very closely and to refrain from excessive supplementation with levocarnitine in affected patients with VLCAD deficiency.
476 - Clinical, Laboratory Data, and Outcome of 7 Patients Affected of Multiple Acyl-CoA Dehydrogenase Deficiency (Glutaric Aciduria Type II) and Report of ETFDH Mutation in Neonatal Form
Talieh Zaman1, Ali Rahmanifar2, and Shirin Moarefian2
1Clinical and Research Unit, Lachine, Montreal, Quebec, Canada
2Clinical and Research Unit of Iranian National Society, Tehran, Iran
477 - Pathophysiology of 3-Hydroxybutyrate Dehydrogenase (3HBD) Deficiency in Ketone Body Metabolism Using a Bdh1 Knockout Mouse Model
Hiroki Otsuka1, Takeshi Kimura1, Yasuhiko Ago1, Hideo Sasai1, Mina Nakama2, Yuka Aoyama3, Elsayed Abdelkreem1, Hidenori Ohnishi1, Masatake Osawa4, Seiji Yamaguchi5, Yusuke Kawashima6, Osamu Ohara6, and Toshiyuki Fukao1
1Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
2Division of Clinical Genetics, Gifu University Hospital, Gifu, Japan
3Department of Biomedical Sciences, College of Life and Health Sciences, Chubu University, Kasugai, Japan
4Department of Regenerative Medicine and Applied Medical Sciences, Gifu University, Gifu, Japan
5Department of Pediatrics, Graduate School of Medicine, Shimane University, Izumo, Japan
6Laboratory for Integrative Genomics, Riken Center For Integrative Medical Sciences (Ims), Yokohama, Japan
478 - Novel Variant in the ETFDH Found in Twins With Glutaric Acidemia Type 2
Alvaro Serrano Russi
Children’s Hospital Los Angeles, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
CC and JC were product of an uncomplicated fraternal twin pregnancy. Newborn screening collected at 25 hours of life showed elevation of C8, C12, C14 and C14:1 acylcarnitines (1.850 µM (<0.6), 3.450 µM (<2), 1.680 µM (1.680) and 1.940 µM (<0.8)) for twin A and for C8, C10, C14:1 (1.2 µM (<0.6); 1.710 µM (<0.65), and 1.1 µM (<0.8)) for twin B. Plasma acylcarnitine profile on both twins showed at 5 days of life elevation of multiple acylcarnitines specially C12-C18. Comprehensive fatty acid oxidation gene panel showed the presence of a pathogenic variant in the ETFDH denominated c.250G>A (A84 T) and a variant of unknown significance denominated c.684G>T (K228 N) in both twins. Parental testing showed they were inherited in trans. Twin A additionally carried an heretozygous likely pathogenic variant in the ACADS denominated c.322G>A (p.G108 S) and a variant of unknown significance in the SLC22A5 denominated c.1043T>C (I348 T). Baseline echocardiogram and liver function testing was normal. Patients were recommended fasting avoidance and were started on 100 mg of Riboflavin daily and 100 mg of Coenzyme Q daily. The ETFDH variant c.250G>A is known to be prevalent in Asian populations but the variant c.684G>T has never been described.
479 - Mitochondrial-Targeted Compounds Improve Mitochondrial Bioenergetics Disturbance in Very Long-Chain Acyl-CoA Dehydrogenase Deficient Fibroblasts
Bianca Seminotti1, Al-Walid Mohsen2, Guilhian Leipnitz3, Anuradha Karunanidhi2, Vera Roginskaya4, Bennett Van Houten4, Peter Wipf5, and Jerry Vockley2
1Division of Medical Genetics, Department of Pediatrics, University of Pittsburgh, Porto Alegre, RS, Brazil
2Division of Medical Genetics, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
3Ppg Ciências Biológicas Bioquímica, Depto Bioquímica, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
4Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, PA, USA
5Department of Chemistry, University of Pittsburgh, Pittsburgh, PA, USA
480 - Clinical Presentation and Outcome in a series of 32 Patients With 2-Methylacetoacetyl-coenzyme A Thiolase (β-Ketothiolase, MAT) Deficiency
Jörn Oliver Sass1, Robert Niklas Schmitt2, Sonja Marina Schlatter2, Corinne Gemperle-Britschgi3, Volker Berg4, Mahmut Çoker5, Anibh M. Das6, Terry Derks7, Gülden Gökçay8, Sema Kalkan Uçar5, Vassiliki Konstantopoulou9, G. Christoph Korenke10, Amelie Sophia Lotz-Havla11, Andrea Schlune12, Christian Staufner13, Christel Tran14, Gepke Visser15, K. Otfried Schwab2, Toshiyuki Fukao16, Mehmet Cihan Balcı, Mübeccel Demirkol, and Sarah C. Grünert2
1Bonn-Rhein-Sieg University of Applied Sciences, Rheinbach, Germany
2Dept Gen Pediatr, Adol Med & Neonatol, Med Ctr, Univ Freiburg, Freiburg, Germany
3Div Clin Chem Biochem and Child Res Ctr, Univ Child Hosp Zürich, Zürich, Switzerland
4Elbe Kliniken, Stade, Germany
5Metab Unit, Dept Pediatr, Ege Univ Med Fac, Izmir, Turkey
6Univ Child Hosp, Hannover Med School, Hannover, Germany
7Sec Metab Dis, Beatrix Child Hosp, Univ Med Ctr Groningen, Groningen, Netherlands
8Div Pediatr Nutr Metab, Dept Pediatr, Istanbul Med Fac, Istanbul Univ, Istanbul, Turkey
9Dept Pediatr, Med Univ Vienna, Vienna, Austria
10Dept Pediatr Neurol, Klinikum Oldenburg, Oldenburg, Germany
11Dept Iem, Dr. Von Hauner Child Hosp, Ludwig-Maximilians Univ, Munich, Germany
12Dept Gen Pediatr, Neonatol, Pediatr Cardiol, Univ Child Hosp, Heinrich Heine Univ, Düsseldorf, Germany
13Div Neuropediatr & Pediatr Metab Med, Dept Gen Pediatr, Univ Heidelberg, Heidelberg, Germany
14Ctr Mol Dis, Med Genet Serv, Lausanne Univ Hosp (Chuv), Lausanne, Switzerland
15Wilhelmina Child Hosp, Univ Med Ctr Utrecht, Utrecht, the Netherlands
16Dept Pediatr, Grad School Med, Gifu Univ; Div Clin Genet, Gifu Univ Hosp, Gifu, Japan
Beta-ketothiolase deficiency (2-methylacetoacetyl-coenzyme A thiolase deficiency, MATD, OMIM #203750) is an inborn error of ketone body utilization and isoleucine catabolism. It is caused by mutations in the ACAT1 gene and may present with metabolic ketoacidosis. In order to obtain a more comprehensive view on this disease, we have analyzed clinical and biochemical data as well as information on ACAT1 mutations of 32 patients from 12 metabolic centers in Germany, Turkey, the Netherlands, Austria, and Switzerland. Data were collected on-site by two medical students who, supported by the local physicians, extracted data from medical records. Patients were between 23 months and 27 years old, more than half of them were offspring of consanguineous parents. 63% of the study participants presented with a metabolic decompensation while most others were identified via newborn screening or family studies. In symptomatic patients, age at manifestation ranged between 5 months and 6.8 years. Only 7% developed a major mental disability, while the vast majority was cognitively normal. Enzyme data were available for 13 patients, all showing reduced or non-detectable MAT activity. More than one third of the identified mutations in ACAT1 were intronic mutations which are expected to disturb splicing. Our work further extends the mutation spectrum known for ACAT1 by two missense mutations (p.Gln101Lys, p.Lys124Glu and c.1253G>A), one frame shift mutation (p.Glu154Aspfs*4) and three intronic sequence variants, which are expected to affect splice sites (c.334+1G>A, c.826+5_826+9delGTGTT and c.940+1G>T). In agreement with previous reports, no clear genotype-phenotype correlation could be found. Although 81% received a protein-restricted diet at least temporarily, no obvious negative consequences could be found in patients without continuous protein restriction. Our study underlines that the prognosis in MATD is good and MAT deficient individuals may remain asymptomatic, if diagnosed early and preventive measures are applied.
481 - 3-Hydroxy-3-Methylglutaryl-Coenzyme A Lyase Deficiency: Clinical Presentation and Outcome in a Series of 37 Patients
Jörn Oliver Sass1, Sonja Marina Schlatter2, Robert Niklas Schmitt2, Corinne Gemperle-Britschgi3, Lenka Mrázová4, Mehmet Cihan Cihan Balci5, Anibh M. Das6, Mübeccel Demirkol5, Maaike de Vries7, Gülden Gökçay5, Johannes HaüBerle8, Sema Kalkan Uçar9, Amelie Sophia Lotz-Havla10, Thomas Lücke11, Dominique Roland12, René Santer13, Andrea Schlune14, Christian Staufner15, Felix Bischof, Mahmut Çoker, Grant A. Mitchell, Frank Rutsch, K. Otfried Schwab2, and Sarah C. Grünert2
1Bonn-Rhein-Sieg University of Applied Sciences, Rheinbach, Germany
2Dept Gen Pediatr, Adol Med & Neonatol, Med Ctr, Univ Freiburg, Freiburg, Germany
3Div Clin Chem Biochem and Child Res Ctr, Univ Child Hosp Zürich, Zürich, Switzerland
4Inst Imd, Charles Univ, 1st Fac Med & Gen Univ Hosp Prague, Prague, Czech Republic
5Div Pediatr Nutr Metab, Dept Pediatr, Istanbul Med Fac, Istanbul Univ, Istanbul, Turkey
6Dept Pediatr, Hannover Med School, Hannover, Germany
7Radboud Univ Med Ctr, Nijmegen, Netherlands
8Div Metab and Child Res Ctr, Univ Child Hosp Zürich, Zürich, Switzerland
9Metab Unit, Dept Pediatr, Ege Univ Med Fac, Izmir, Turkey
10Dept Iem, Dr. Von Hauner Child Hosp, Ludwig-Maximilians Univ, Munich, Germany
11Dept Neuropediatr, Univ Child Hosp, Ruhr Univ Bochum, Bochum, Germany
12Iem Unit, Inst Pathol Genet, Charleroi, Gosselies, Belgium
13Dept Pediatr, Univ Med Ctr Hamburg-Eppendorf, Hamburg, Germany
14Dept Gen Pediatr, Neonatol, Pediatr Cardiol, Univ Child Hosp, Heinrich Heine Univ, Düsseldorf, Germany
15Div Neuropediatr & Pediatr Metab Med, Dept Gen Pediatr, Univ Heidelberg, Heidelberg, Germany
3-hydroxy-3-methylglutaryl-coenzyme A lyase deficiency (HMGCLD, OMIM #246450) is a rare inborn error of ketone body synthesis and leucine degradation. It is caused by mutations in the HMGCL gene. In order to obtain a comprehensive view on this disease, we have analyzed clinical and biochemical data as well as information on HMGCL mutations of 37 patients (35 families) from metabolic centers in Belgium, Germany, the Netherlands, Switzerland, and Turkey. Data were collected on-site and extracted by two medical students from the medical records, with support by the local physicians. Patients were between 4 months and 40 years old, and half of them were offspring of consanguineous parents. All patients were symptomatic at some stage with 94% presenting with an acute metabolic decompensation. The most common clinical symptoms were recurrent vomiting, seizures, and impaired vigilance, while the main laboratory findings were hypoglycemia and metabolic acidosis. In 50% of the patients, the disorder manifested neonatally, mostly within the first days of life. Only 8% of patients presented first symptoms after one year of age. Six patients died prior to data collection. Long-term treatment mainly comprised protein- and leucine-restricted diet and administration of L-carnitine. In addition to mental impairment, long-term neurological complications were frequent. Half of the patients had a normal cognitive development while the remainder showed psychomotor deficits. Besides microcephaly in 29% of the patients, physical development appeared overall normal. In more than 50% of the study participants, HMGCL enzyme activity was assessed and confirmed the diagnosis. We identified seven novel HMGCL mutations. In agreement with previous reports, no clear genotype-phenotype correlation could be found. This is the largest cohort of HMGCLD patients reported so far, demonstrating that HMGCLD is a potentially life-threatening disease with variable clinical outcome. Our findings suggest that the clinical course of HMGCLD cannot be predicted accurately from HMGCL genotype and that the overall outcome in HMGCLD is limited.
482 - Results From a 78-Week Single-Arm, Open-Label Phase 2 Study to Evaluate UX007 in Pediatric and Adult Patients With Moderate to Severe Long-Chain Fatty Acid Oxidation Disorders (LC-FAOD)
Jerry Vockley1, Barbara Burton2, Gerard Berry3, Nicola Longo4, John Phillips5, Amarilis Sanchez-Valle6, Pranoot Tanpaiboon7, Stephanie Grunewald8, Elaine Murphy9, Alexandra Bowden10, Wencong Chen10, Chao-Yin Chen10, Jason Cataldo10, Deborah Marsden10, and Emil Kakkis10
1University of Pittsburgh, Pittsburgh, PA, USA
2Ann And Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
3Boston Children’s Hospital, Boston, MA, USA
4University of Utah, Salt Lake City, UT, USA
5Vanderbilt University Medical Center, Nashville, TN, USA
6Usf Health, Morsani College of Medicine, Tampa, FL, USA
7Children’s National Health System, Washington, DC, USA
8Great Ormond Street, Ucl Institute of Child Health, London, United Kingdom
9National Hospital for Neurology and Neurosurgery, London, United Kingdom
10Ultragenyx Pharmaceutical Inc., Novato, CA, USA
A single-arm, open-label phase 2 study was conducted to evaluate safety and efficacy of UX007 (a highly purified, synthetic seven carbon fatty acid triglyceride) for 78 weeks in 29 pediatric and adult patients with moderate-to-severe LC-FAOD (24 subjects completed 78 weeks). LC-FAOD are autosomal recessive genetic disorders caused by defects in mitochondrial fatty acid oxidation enzymes active with long-chain substrates that lead to a general deficiency of energy intermediates and accumulation of toxic fatty acid intermediates causing a variety of serious clinical manifestations. UX007 is being investigated as treatment for LC-FAOD. The mechanism of action of UX007 in restoring energy metabolism is dependent on its medium chain length and odd-carbon properties. UX007 was titrated to a target dose of 25%-35% of total daily caloric intake (mean 31%). Major clinical events (MCE; hospitalizations, emergency room visits, and emergency home interventions due to rhabdomyolysis, hypoglycemia, and cardiomyopathy) were captured retrospectively from medical records for 18-24 months prior to UX007 initiation and compared with the 18 months post-UX007. Prior to initiating UX007, 93% subjects were on MCT therapy. UX007 treatment significantly reduced the number and duration of MCEs. The overall mean annualized event rates decreased from 1.69 to 0.88 events/year (P = .0208) and the mean annualized duration rate decreased from 5.96 to 2.96 days/year (P = .0284) following UX007 initiation. Hospitalizations due to rhabdomyolysis, the predominant MCE, also decreased from 1.03 to 0.63 events/year (P = .1044) following UX007 initiation. Initiation of UX007 eliminated hypoglycemia events leading to hospitalization (0.30 vs 0 hospitalization events/year; P = .0667) and ICU care (0.05 vs 0 ICU events/year; P = .1609). Adult subjects reported significant improvements in the SF-12 Physical Component Summary Scale (n = 5, P = .0354), while pediatric subjects reported significant improvements in the SF-10 Physical Summary Scores (n = 3, P < .0001). Finally, UX007 treatment reduced cardiomyopathy events by 69.6% (0.07 vs 0.02 events/year; P = .3090). The most common related treatment-emergent adverse events (TEAEs) were diarrhea, abdominal or gastrointestinal pain, vomiting, and acne, with most mild to moderate in severity. Conclusion: Major clinical events were significantly reduced following UX007 treatment in contrast to pre-treatment, during which most subjects were treated with MCT.
483 - Bi-Allelic Null Mutations in the SCAD Gene Results in Toxic Levels of Butyric Acids
Sarah Fogh1, Malene Hansen2, Zahra Nochi1, Rikke Katrine Jentoft Olsen1, Lars Aagaard3, and Niels Gregersen1
1Aarhus University Hospital and Aarhus University, Aarhus, Denmark
2Aarhus University Hospital, Aarhus, Denmark
3Aarhus University, Aarhus, Denmark
484 - Carnitine Palmitoyl Transferase Deficiency in Indian Patients
Anil Jalan1, Durga Shinde1, Ketki Kudalkar1, Rishikesh Jalan1, Monal Borugale1, Rasika Tawde1, Neelam Yadav1, Gauri Gaikwad1, Claudia Cozma2, Sabriana Eichler2, Susanne Zielke3, and Arndt Rolfs3
1Navi Mumbai Institute of Research in Mental and Neurological Hanidcap, Navi Mumbai, India
2Centogene Ag, Institute of Rare Diseases, Rostock, Germany
3Medical Faculty, Albrecht Kossel Institute, University of Rostock, Rostock, Germany
485 - VLCAD Deficiency Related Chronic Inflammation Pattern is Suggestive of Systemic Mediators
Megan Beck1, Angel Lin1, Joshua Michel2, Abbe Vallejo2, Jerry Vockley3, and Henry Joel Mroczkowski1
1Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
2Department of Immunology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
3Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
486 - Primary systemic Carnitine deficiency: Clinical Features, Biochemical Findings, and Treatment Outcome in 14 Patients
Emanuela Manea, Stephanie Grunewald, Maureen Cleary, Anupam Chakrapani, Emma Footitt, Shamima Rahman, and Spyros Batzios
Great Ormond Street Hospital, London, United Kingdom
487 - Multiple Defects in Several Genes Appear to Act Synergistically in a Complex Case of Virally Induced Rhabdomyolysis
Karolina Stepien1, Simon Olpin2, Christian Hendriksz1, Joanne Croft2, Camilla Scott2, Diane Green1, Janette Banks1, Andrew Oldham1, and Ana Jovanovic1
1Adult Inherited Metabolic Disorders, Salford Royal NHS Foundation Trust, Salford, United Kingdom
2Clinical Chemistry Department, Sheffield Children’s Hospital, Sheffield, United Kingdom
Fatty acid oxidation defects (FAOD) are a group of metabolic disorders that present with a variety of phenotypic features. Hypoglycaemia and myopathy and severe rhabdomyolysis may occur in individuals who have molecular changes in more than one gene resulting in synergistic effects. We describe a case of 27-year-old female patient who presented with 3 episodes of rhabdomyolysis precipitated by viral infections and pneumonia between the age of 17 and 25. Her CK increased to 213 000 U/L and was complicated by acute kidney injury requiring admission to ICU. There was a positive family history for Malignant Hyperthermia Syndrome (MHS). Her BMI was 46 kg/m2 and her intention was to reduce her body weight, but prolonged fasting, low calorie intake, infrequent meals and exercise exacerbated symptoms affecting predominantly her legs. In addition, hot temperatures aggravated her symptoms even more (‘shaky legs’). MCT product was introduced prior to mild anaerobic exercises to prevent severe myalgia. Initial investigations in muscle found a susceptibility to MHS. Blood acylcarnitines indicated possible CPT2 deficiency. Genetic testing confirmed compound heterozygote mutations in CPT2 c.[338C>T(;)1933dup], p.[Ser113Leu(;)Glu645 fs] and one “mild” known pathogenic mutation in ACADVL c.848T>C, p.[Val283Ala]. Both mutations are reported to be thermolabile. Skin fibroblasts confirmed she had deficient CPT2 enzyme activity at 14% of controls. Fibroblast fatty acid oxidation flux (FAOF) for [9,10-3 H]palmitate at 37 C and 41 C was 10% and 6% respectively. Comparative data in 11 “pure” CPT2 deficient myopathic patients resulting from several different mutations, including homozygous and compound heterozygous p.S113 L mutations, gave mean CPT2 enzyme activity of 14±3.5% and palmitate flux at 37 C and 41 C of 55 ± 24% and 21 ± 9% (n = 7) respectively. Myalgia in combination with recurrent rhabdomyolysis warrants thorough biochemical, genetic and histological investigations. Studies should not be stopped after one abnormality is found, in particular, when the severity of clinical presentation does not fit with the result of genetic analysis. In our case CPT2 activity was similar to 11 other “pure” myopathic CPT2 patients but FAOF was the lowest we have encountered in CPT2 deficiency. We strongly suspect synergistic interaction within the fatty acid metabolome that is contributing to the more severe phenotype. This may also be additionally complicated by a MHS susceptibility.
488 - FLAD1, a Recently Described Gene Associated to Multiple Acyl-CoA Dehydrogenase Deficiency (MADD) is Mutated in a Patient With Myopathy, Scoliosis, and Cataracts
Judit Garcia-Villoria1, Begoña de Azua2, Frederic Tort1, Signe Mosegaard3, Olatz Ugarteburu1, Laura Texido1, Rikke Katrine Jentoft Olsen3, and Antonia Ribes1
1Hospital Clinic de Barcelona And Ciberer, Barcelona, Spain
2Hospital Son Llatzer, Palma de Mallorca, Spain
3Aarhus University and Aarhus University Hospital, Aarhus, Denmark
Multiple acyl-CoA dehydrogenase deficiency (MADD) is a defect involved in electron transfer to the mitochondrial respiratory chain. Mutations in eight different genes have been associated to MADD. Clinically, it can be presented in the severe neonatal form to the adult form with metabolic acidosis, vomiting, myopathy, muscle pain, or weakness. Some patients are riboflavin responsive. We present a 6 months old female patient with bilateral cataracts. At 1 year of life, she developed scoliosis and later on myopathy. Metabolic investigations at 6 months ruled out galactosemia, lysosomal and peroxisomal disorders. The urinary organic acid profile showed increased ethylmalonic acid, and medium- and long-chain acylcarnitines were increased in plasma (C6, C8, C10, C10:1, C12, C14, C14:1, C14:2, C16:1, C18, and C18:1). These results were suggestive of MADD. The diagnosis was confirmed by the study of deuterated palmitate oxidation in cultured fibroblasts. The patient was treated with riboflavin and low-fat diet, but we could not observe any improvement on the clinical or biochemical data. Molecular studies by NGS using our own-designed Haloplex panel (Agilent technology) revealed two new heterozygous mutations in FLAD1 gene: c.1555-3C>G and c.797_798delAGinsT. Both mutations have been confirmed in her parents. Western blot in fibroblasts showed total lack of the full-length cytosolic FADS form (50 kDa), but presence of the truncated 26 kDa protein that may allow some FADS activity to be produced. FADS protein is encoded by FLAD1 gene and is implicated in the synthesis of FAD. In 2016 nine patients have been published in a single article (Olsen RK et al. Am J Hum Genet. 2016; 98:1130-1145), some of them were riboflavin-responsive while our patient was not. Cataracts is a peculiar finding not reported in other patients with FADS deficiency, but it has been reported in the more severe forms of MADD.
489 - Clinical and Molecular Evaluation of 15 Korean MCAD Patients Detected by Newborn Screening
Sook Za Kim1, Young Mi Jeon1, Wung Joo Song1, Seon Ho Lee1, Seiji Yamaguchi2, and Arnold Strauss3
1Korea Genetics Research Center, Cheongju-Si, South Korea
2Shimane University School of Medicine, Izumo, Japan
3Cincinnati Children's Hospital, Cincinnati, OH, USA
490 - A Mitochondrial-Targeted Electron Scavenger and a Cardiolipin Binding Peptide Decrease Superoxide Generation and Improve Mitochondrial Respiration in ACAD9-Deficient Fibroblasts
Guilhian Leipnitz1, Bianca Seminotti2, Al-Walid Mohsen2, Anuradha Karunanidhi2, Vera Roginskaya3, Peter Wipf4, Bennett Van Houten3, and Jerry Vockley2
1Ppg Ciências Biológicas Bioquímica, Depto de Bioquímica, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
2Division of Medical Genetics, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
3Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, PA, USA
4Department of Chemistry, University of Pittsburgh, Pittsburgh, PA, USA
Acyl-CoA dehydrogenase 9 (ACAD9) is a flavoprotein that catalyzes the first step in long-chain fatty acid β-oxidation and acts as an assembly factor for mitochondrial respiratory chain complex I. Individuals with ACAD9 deficiency present with progressive encephalomyopathy, recurrent Reye syndrome, and cardiomyopathy that can be fatal. Although some patients are responsive to riboflavin therapy, there are limited treatment options for this disorder. We evaluated the effect of potential protective compounds on superoxide generation and mitochondrial respiration in fibroblasts of an ACAD9-deficient patient. Patient fibroblasts were cultured in medium without glucose for 48 to 72 hr to assess the ability of ACAD9-deficient cells to accommodate the shift of energy source from glucose, and the effect of JP4-039, a mitochondrial targeting free radical scavenger, as well as a novel cardiolipin targeting peptide on superoxide production and oxygen consumption. Superoxide generation was increased, whereas basal respiration and reserve capacity were decreased in ACAD9-deficient cells, compared to normal cells. While either JP4-039 or the cardiolipin targeting peptide decreased superoxide levels, the antioxidants N-acetylcysteine, trolox, resveratrol, and mitoQ, and the pan-PPAR agonist bezafibrate did not reduce superoxide levels. JP4-039 and the peptide increased basal respiration and reserve capacity in deficient cells as well. These findings suggest that some of the presumed damaging biochemical abnormalities caused by ACAD9 deficiency can be alleviated by JP4-039 and the novel cardiolipin targeting peptide, in addition to improving bioenergetics in ACAD9-deficient fibroblasts. This provides the impetus for further evaluation of these molecules as potential therapeutics for this disorder.
491 - Assessments of Exercise Tolerance and Muscle Function in Long Chain-Fatty Acid Oxidation Disorders (LC-FAOD): Results From a Phase 2 Open Label Study of UX007
Jill Mayhew1, Jerry Vockley2, Barbara Burton3, Gerard Berry4, Nicola Longo5, John Phillips6, Amarilis Sanchez-Valle7, Pranoot Tanpaiboon8, Stephanie Grunewald9, Elaine Murphy10, Wencong Chen1, Chao-Yin Chen1, Jason Cataldo1, Deborah Marsden1, Alexandra Bowden1, Emil Kakkis1, Alison Skrinar1, and Reed Humphrey11
1Ultragenyx Pharmaceutical, Inc., Novato, CA, USA
2University of Pittsburgh, Pittsburgh, PA, USA
3Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
4Boston Children’s Hospital, Boston, MA, USA
5University of Utah, Salt Lake City, UT, USA
6Vanderbilt University Medical Center, Nashville, TN, USA
7Usf Health, Morsani College of Medicine, Tampa, FL, USA
8Children’s National Health System, Washington, DC, USA
9Great Ormond Street, Ucl Institute of Child Health, London, United Kingdom
10National Hospital for Neurology and Neurosurgery, London, United Kingdom
11University of Montana, Missoula, MT, USA
LC-FAOD are autosomal recessive genetic disorders caused by defects in mitochondrial fatty acid oxidation enzymes active with long-chain substrates. These defects lead to a general deficiency of energy intermediates and accumulation of toxic fatty acid intermediates resulting in serious clinical manifestations. In a Phase 2 open-label study, the effect of UX007 (a highly purified, synthetic seven carbon fatty acid triglyceride) on exercise tolerance and muscle function was investigated. Exercise intolerance was reported in the LC-FAOD specific medical histories of 21/29 (72%) of subjects enrolled in the Phase 2 study. Tests of exercise tolerance and muscle function were performed in the cohort of subjects ≥6 years of age that were able to comply and follow test instructions safely and reliably. Cycle ergometry was included as a measure of exercise tolerance and performed at an intensity and duration conducive to the reduction of glycogen stores and oxidation of fatty acids by exercised muscle to evaluate the effect of UX007 treatment in subjects with inherent defects in fatty acid oxidation. Exercise tolerance was assessed by workload and duration at a fixed heart rate during a 40-minute protocol. A 12minute walk test (12MWT) was incorporated into the study design as a measure of muscle function. The distance walked in meters was assessed at 6 and 12 minutes. In the ergometry test, improvements were observed in both workload (watts) and duration (mins) following UX007 treatment (n = 7). After 24 weeks of UX007 treatment, mean workload increased by 60% from 744.6 to 1191.4 watts (median: 127.5; min, max: −388, +2438; Least Squares (LS) mean change: 423.6, P = .1518). Improvements in duration were also noted with mean test times improving from 9.3 ± 5.1 mins (range: 5-15) to 20.4 ± 17.0 mins (range: 10-40) in the 3 subjects unable to complete the 40-minute exercise protocol at Baseline. No further improvements were noted after an additional 48 weeks of treatment however, the interpretation was limited by a smaller sample size. In the 12MWT, the mean distance walked increased 28% from 673.4 meters to 861.4 meters after 18 weeks of UX007 treatment (median: 93.5; min, max: −80, +880; LS Mean change: 181.4, P = .0830) (n = 8). This increase was maintained after an additional 42 weeks of treatment. These data suggest UX007 treatment improves exercise tolerance and muscle function in LC-FAOD patients and supports the use of these assessments in this patient population.
492 - Molecular and Biochemical Characteristics of Patients With LCHADD From Ukraine
Oksana Barvinska1, Natalia Olkhovych1, Natalia Mytsyk1, Natalia Pichkur2, and Natalia Gorovenko3
1Laboratory of Medical Genetics, Center of Orphan Disorders Ncsh Okhmatdyt, Kyiv, Ukraine
2Center of Orphan Disorders Ncsh Okhmatdyt, Kyiv, Ukraine
3Department of Medical and Laboratory Genetics of Shupyk Nmapo, Kyiv, Ukraine
493 - Carnitine Deficiency Secondary to Methyl-Tetra-Hidrofolatoredutase Mutation: Case Report
Luisa Simonsen, Helio Rocha, Natasha Geisel, Julia Albuquerque, Flavia Nardes, Nathalia Fernandes, Marlos Martins, Leonardo Campos, Marta Felix, Nathalie Canedo, Bruna Barros, Monica Moretzsohn, Tamires Camargo, Viviane Santos, Lilian Licurgo, and Alessandra Braga
Ippmg Ufrj, Rio de Janeiro, RJ, Brazil
The aim of this study is to draw attention to the rare association between carnitine deficiency and enzymatic mutation methyl-tetra-hidrofolatoredutase, diagnosis usually thoughtless, resulting in progressive myopathy. We describe a retrospective case report using medical record data collection. Patient, male, 12 years bearer of Takayasu arteritis that after two months of treatment with methotrexate presented progressive proximal myopathy, standard MRI showed inflammatory myopathy and two muscle biopsies with accumulation of lipid and glycogen, suggestive of carnitine deficiency. Heterozygous mutation was detected in the C677 T MTHFR gene with elevated serum homocysteine and it was started replacement with L-carnitine with progressive improvement in muscle strength and decrease of muscle enzymes, returning to walk in 15 days. The pattern of inflammatory myopathy is described as a reflex of muscle infiltration by fatty acids. Disorders of fatty acid metabolism generate accumulation of acylcarnitine. This accumulation of lipid in the muscle causes inflammatory lesion and progressive muscle damage, similar to inflammatory myopathy. Muscle biopsies, with absence of atrophy of inflammatory infiltrate fibers and presenting lipid infiltration, suggest carnitine deficiency. Carnitine is a facilitator of transport of long chain fatty acids through mitochondria, modulates the intramitochondrial CoA / acylCoA ratio and alternative metabolic pathways. The clinical manifestations vary from the age of presentation according to the cause, and may present as myopathic or systemic form. In myopathic form, serum carnitine levels may be normal (measurement is not essential for diagnosis). MTHFR is an enzyme involved in the homocysteine pathway, the severity of its deficiency depends on the level of enzymatic activity. The clinical deficiency of MTHFR occurs in homozygotes and heterozygotes usually do not present clinical manifestations except in the case of concomitant folate deficiency, as in the use of methotrexate, an analog of folic acid capable of competitively and irreversibly inhibiting the enzyme in question.
494 - Carnitine Acyl Carnitine Translocase Deficiency With Severe Hyperammonemia and Hypoglycemia
Asli İnci1, Ilyas Okur1, Asburçe Olgaç1, Emine Akkuzu2, Gürsel Biberoğlu1, Fatih Ezgü1, and Leyla Tümer1
1Gazi University School of Medicine, Division of Pediatric Metabolism and Nutrition, Ankara, Turkey
2Gazi University School of Medicine, Division of Pediatric Intensive Care Unit, Ankara, Turkey
495 - Short Chain Fatty Acid Oxidation Defect in an Adult Patient With Refractory Seizures
Asli İnci, Leyla Tümer, Ilyas Okur, Gürsel Biberoğlu, and Fatih Ezgü
Division of Pediatric Metabolism and Nutrition, Gazi University School of Medicine, Ankara, Turkey
496 - Severe Neonatal Manifestation of Long Chain 3-Hydroxyacyl-CoA Dehydrogenase deficiency: First Report After 14 Years of Expanded Newborn Screening at the National Children’s Hospital, Costa Rica
Jorge Delgado1, Mildred Jiménez-Hernández2, Alejandra Reuben2, Jonessy Quesada1, Ramsés Badilla-Porras1, and Manuel Saborio1
1Clinical Genetics and Metabolic, National Children’s Hospital, San Jose, Costa Rica
2National Newborn and High Risk Screening Laboratory, National Children’s Hospital, San Jose, Costa Rica
497 - Heterozygous Carriers of Succinyl-CoA: 3-Oxoacid CoA Transferase Deficiency can Develop Severe Ketoacidosis
Hideo Sasai1, Yuka Aoyama2, Hiroki Otsuka1, Elsayed Abdelkreem1, Yasuhiro Naiki3, Mitsuru Kubota4, Yuji Sekine5, Masatsune Itoh6, Mina Nakama7, Hidenori Ohnishi1, Yoji Fujiki8, Osamu Ohara8, and Toshiyuki Fukao1
1Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
2Department of Biomedical Sciences, College of Life and Health Sciences, Chubu University, Kasugai, Japan
3Division of Endocrinology and Metabolism, National Center for Child Health and Development, Tokyo, Japan
4Dept of General Pediatr and Interdisciplinary Med, National Center for Child Health and Development, Tokyo, Japan
5Department of General Pediatrics, Shizuoka Children’s Hospital, Shizuoka, Japan
6Department of Pediatrics, Kanazawa Medical University, Kanazawa, Japan
7Division of Clinical Genetics, Gifu University Hospital, Gifu, Japan
8Department of Technology Development, Kazusa Dna Research Institute, Kisarazu, Japan
Succinyl-CoA:3-oxoacid CoA transferase (SCOT, gene symbol OXCT1) deficiency is an autosomal recessive disorder in ketone body utilization that results in severe recurrent ketoacidotic episodes in infancy. More than 30 patients with this disorder have been reported and to our knowledge, their heterozygous parents and siblings have had no apparent ketoacidotic episodes. Over 5 years (2008–2012), of the patients that presented with severe ketoacidosis who were suspected as having SCOT deficiency, we identified a heterozygous OXCT1 mutation in four cases (Case1 p.R281C, Case2 p.T435 N, Case3 p.W213*, and Case4 c.493delG). To confirm their heterozygous state, we performed a multiplex ligation-dependent probe amplification analysis on the OXCT1 gene which excluded the presence of large deletions or insertions in another allele. A sequencing analysis of subcloned full-length SCOT cDNA showed that wild-type cDNA clones were present at reasonable rates to mutant cDNA clones. Over the following 2 years (2013-2014), we analyzed OXCT1 mutations in six more patients presenting with severe ketoacidosis (blood pH ≦7.25 and total ketone body ≧10 mmol/L) with non-specific urinary organic acid profiles. Of these, a heterozygous OXCT1 mutation was found in two cases (Case5 p.G391D, Case6 p.R281C). Moreover, transient expression analysis revealed R281C and T435 N mutants to be temperature-sensitive. This characteristic may be important because most patients developed ketoacidosis during infections. Our data indicate that heterozygous carriers of OXCT1 mutations can develop severe ketoacidotic episodes in conjunction with ketogenic stresses.
498 - Activation of Protective Systems in Fatty Acid Oxidation Disorders can lead to Deleterious Outcomes
Martin Lund, Niels Gregersen, and Rikke Katrine Jentoft Olsen
Research Unit for Molecular Medicine, Dept. Of Clinical Medicine, Aarhus University Hospital., Aarhus, Denmark
One consequence of long-chain fatty acid oxidation (FAO) disorders is excessive accumulation of free fatty acids within cells. In a healthy cell or tissue, the peroxisome proliferator-activated receptors (PPARs) and other cellular pathways will be activated by these fatty acids and increase expression and activity of proteins associated with FAO and other aspects of lipid metabolism. This reduces the level of free fatty acids to below cytotoxic levels, by oxidation, export or incorporation into membrane lipids. The PPAR system can also be activated pharmacologically; a classic example of PPAR agonists is the fibrate group. In recent years, the bezafibrate has been proposed as a pharmacological treatment for milder forms of long-chain FAO disorders. In vitro studies have shown promising results, but small clinical trials less so. The effect on the cellular redox state of pharmacologically activating the PPAR system is not known. Effects could include potentially deleterious aspects, such as activating mitogenesis of inherently dysfunctional mitochondria and increasing expression of mutant protein. Conversely, PPAR activation also initiates protective systems, such as expression of antioxidant proteins. We set out to investigate cellular protection against oxidative stress and survival under external heat stress after bezafibrate treatment. We found that during heat stress mitochondrial superoxide production increases in very long-chain acyl-CoA dehydrogenase deficient patient dermal fibroblasts treated with bezafibrate (n = 6), compared to similarly treated controls (n = 6). Superoxide production was also greater in bezafibrate treated patient fibroblasts undergoing heat stress, than in patient fibroblasts undergoing heat stress without prior bezafibrate treatment. Likewise, the capacity of bezafibrate-treated patient fibroblasts to maintain peptide antioxidant (i.e. glutathione) levels during deceased, which leads to faster cell death during heat stress. The increased predisposal to stress induced cellular damage may partially or completely counteract the beneficial aspects of bezafibrates ability to increase the baseline FAO capacity. This points to the importance of supportive therapy, to help maintain organelle integrity, as opposed to simply attempting to increase expression of mutant protein and normalize FAO flux.
499 - Multiple Acyl-CoA Dehydrogenase Deficiency due to a Novel Homozygous and Compound Heterozygous Mutation in the ETFDH Gene in 3 South African Patients
Marli Dercksen1, Izelle Smuts2, Engela M Honey3, Michael M Lippert4, Marleen Engelbrecht4, Maryke Schoonen1, Lindi-Maryn Jonck1, Roan Louw1, and Francois H Van Der Westhuizen1
1Human Metabolomics, North-West University, Potchefstroom, South Africa
2Department of Paediatrics and Child Health, Steve Biko Academic Hospital, University of Pretoria, Pretoria, South Africa
3Department Genetics, University of Pretoria, Pretoria, South Africa
4Private Practice, Pretoria, South Africa
500 - Epidemiological and clinical features of Medium-Chain Acyl-CoA Dehydrogenase Deficiency in the Pediatric Population of the Republic of Ireland
Zhubene Mesbah1, Kam Sing Ho1, Ardeshir Monavari2, Patricia Fitzsimons3, Philip Mayne4, and Ellen Crushell2
1The Royal College of Surgeons in Ireland, Dublin, Ireland
2National Centre for Inherited Metabolic Disorders, Dublin, Ireland
3Temple Street Children’s University Hospital, Dublin, Ireland
4The Royal College of Surgeons in Ireland; Temple Street Children’s University Hospital, Dublin, Ireland
501 - Pharmacological Inhibition of Carnitine Palmitoyltransferase 1 Restores Mitochondrial Oxidative Phosphorylation in Human Trifunctional Protein Deficient Fibroblasts
François Labarthe1, Elodie Gouache1, Cécile Acquaviva2, Marine Tardieu1, Jean-François Benoist3, Jean-François Dumas4, Stéphane Servais4, Stephan Chevalier4, Christine Saban2, and Bruno Lefort1
1Chru Tours, Tours, France
2Hospices Civils de Lyon, Lyon, France
3Aphp, Hôpital R Debré, Paris, France
4Inserm U1069, Tours, France
502 - Case Report: Succinyl-CoA:3-Ketoacid CoA Transferase (SCOT) Deficiency
Silvana Kruger Frizzo1, Clarissa Bueno2, Ciro Matsui2, Flavia Piazzon3, Fernanda Monti4, and Fernando Kok3
1Hc /Fmusp, São Paulo, SP, Brazil
2Hc/Fmusp, São Paulo, SP, Brazil
3Hc/Fmusp, Mendelics Análise Genômica, São Paulo, SP, Brazil
4Hc/Fmusp, Sãopaulo, SP, Brazil
503 - Systemic Carnitine Deficiency: Impact of Treatment on Clinical and Biochemical Features in 32 Patients
Mehmet Cihan Balci1, Mubeccel Demirkol2, Mehmet Cihan Cihan Balci3, Koksal Ozgul3, Ali Dursun3, and Gülden Gökçay2
1Tokat State Hospital, Tokat, Turkey
2Division Of Nutrition And Metabolism, Children's Hospital Istanbul Medical Faculty, Istanbul, Turkey
3Division Of Nutrition And Metabolism Children's Hospital Hacettepe Medical Faculty, Ankara, Turkey
504 - Mitochondrial Trifunctional Protein Deficiency Presenting as Recurrent Nonimmune Hydrops in Siblings and Maternal Mirror Syndrome
Katherine Lewis1, Elizabeth Hurrion2, Ricky Price3, Gabrielle Crisp3, Avis Mcwhinney4, George Marshall4, Mark Williams4, Beena Devanapalli5, and James Mcgill1
1Queensland Lifespan Metabolic Medicine Service, Lady Cilento Children’s Hospital, Brisbane, Australia
2Neonatal Critical Care Unit, Mater Health Services, Brisbane, Australia
3Pathology Queensland, Royal Brisbane and Women’s Hospital, Brisbane, Australia
4Mater Pathology, Mater Health Services, Brisbane, Australia
5Nsw Biochemical Genetics, The Children’s Hospital at Westmead, Sydney, Australia
505 - Detection of Allele Frequencies of Common c. 517TC and c.625GA Variants in the ACADS Gene in Turkish Population
Mustafa Kiliç1, Bekir Ergüner2, and Koksal Ozgul3
1Sami Ulus Children Hosp., Metabolism Unit, Ankara, Turkey
2Igbam, Tubitak, Ankara, Turkey
3Hacettepe University, Children Hosp., Metabolism Unit, Ankara, Turkey
Short-chain acyl-CoA dehydrogenase deficiency (SCADD) is a rare inborn error of mitochondrial fatty acid oxidation defect and protein misfolding disorder. Our aim is to find out Turkish patients diagnosed SCADD in literature and detect allele frequencies of two common variants (c.571T>C and c.625G>A) in Turkish population. We found five Turkish patients from unrelated four families diagnosed SCADD with metabolic screening and mutational analyses. We also investigated allele frequencies of common variants of c.517T>C and c.625G>A and detected 0% and 13% respectively. Homozygous c.625G>A variant was also found to be high in Turkish population as it is in the general population. These variants thought to be confer the susceptibility to disease different than other benign polymorphisms, therefore urgent precautions should be taken in case of metabolic stress (starvation, infection, fever) in people who has these genetic variations to prevent sequela of disease.
506 - Missed Case of Novel ACADVL Homozygous Mutation in Infant With Severe Cardiomegaly and Pericardial Effusion
Yoo-Mi Kim
Pusan National University Children’s Hospital, Yangsan, South Korea
507 - Molecular Characterization of ACADM Gene in Argentinean Patients
Carolina Crespo, Hernan Eiroa, Romina Rodriguez, and Luis Pablo Gravina
Hospital de Pediatría Garrahan, Ciudad de Buenos Aires, Argentina
508 - Ketonesters as a Possible Novel Therapeutic Option for Patients With Fatty Acid Oxidation Disorders
Jeannette Bleeker1, Gepke Visser1, Anita Sibeijn-Kuiper2, Rob Wüst3, Ronald Wanders3, Riekelt Houtkooper3, Sacha Ferdinandusse3, Kieran Clarke4, Tim Takken5, Irene Kok6, Monique de Sain-Van Der Velden6, Frits Wijburg3, Pete Cox4, and Jeroen Jeneson2
1Departments of Metabolic Diseases, Wilhelmina Children’s Hospital & Emma’s Children’s Hospital, Utrecht, Amsterdam, the Netherlands
2Department of Neuroscience/ Neuroimaging Center, University Medical Center Groningen, Groningen, the Netherlands
3Department of Metabolic Diseases, Emma’s Children’s Hospital, Academic Medical Center, Amsterdam, the Netherlands
4Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, United Kingdom
5Child Development and Exercise Center, Wilhelmina Children’s Hospital, Utrecht, Netherlands
6Department of Metabolic Diseases, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
509 - Medium Chain Acyl-coA Dehydrogenase Deficiency: The Importance of Fasting Blood Acylcarnitines and Urinary Organic Acid Profile
Maria Teresa Sanseverino1, Angela Sitta2, Patricia Dineck3, Larissa Murussi3, Analida Pinto3, Daniella de Moura Coelho2, Moacir Wajner4, and Carmen Regla Vargas4
1Escola de Medicina da Pucrs Serviço de Genetica Medica Hcpa, Porto Alegre, RS, Brazil
2Serviço de Genetica Medica Hcpa, Porto Alegre, RS, Brazil
3Serviço de Pediatria, Hospital São Lucas Pucrs, Porto Alegre, RS, Brazil
4Ufrgs, Serviço de Genetica Medica Hcpa, Porto Alegre, RS, Brazil
Medium-chain acyl-CoA dehydrogenase deficiency (MCADD) is an autosomal recessive inborn error of mitochondrial fatty acid β-oxidation, caused by mutations in the ACADM gene. Although it is the most commonly inherited disorder of the mitochondrial fatty acid oxidation worldwide, there are few reports of cases and mainly regarding the incidence of the disease in Brazil, once there is not a newborn screening program for MCADD. We report here the case of a 2-year-old female patient with recurrent episodes of hypoglycemia, who was investigated through the Brazilian Network of Inborn Errors of Metabolism (Rede EIM) and presented interesting findings of the accumulated metabolites profile. Blood octanoylcarnitine (C8) and octanoylcarnitine /decanoylcarnitine (C8-C10) ratio increase, as well as a decrease in free carnitine (C0) with normal hexanoylcarnitine (C6), decanoylcarnitine (C10) and decenoylcarnitine (C10:1) levels were found in the tandem mass spectrometry (MS/MS) acylcarnitine profile. In a second blood sample (postprandial), the acylcarnitine profile was clearly normal, while in a third sample (4-hour fasting) it was observed a marked C8, C8/C10 ratio and C10:1 increase, besides the presence of hexanoylglycine in the urinary organic acid analysis by gas chromatography/mass spectrometry (GC/MS). These findings were suggestive of MCAD deficiency, even though we do not have yet the molecular analysis of the patient. This case demonstrates the importance of fasting sample collection (if possible) when there is a suspicion of an error of mitochondrial fatty acid β-oxidation. Considering the possibility that this disease is underdiagnosed in Brazil and that MCADD is a well-known cause of sudden death in infants, the adequate time of biological sample collection could be crucial to diagnosis.
510 - Betaketothiolase Deficiency—Use of Low Dose Insulin Infusion: A Case Report
Sophy Korula and Anna Simon
Christian Medical College and Hospital, Vellore, Tamil Nadu, India
511 - Diagnosis of Fatty Acid Oxidation Disorders: Experience at Quest Diagnostics Nichols Institute Biochemical Genetics Laboratory
Rajesh Sharma, Denise Salazar, Ruben Bonilla-Guerrero, Abdul Reza Davoodi-Semiromi, Julie Neidich, and Felicitas Lacbawan
Quest Diagnostics Nichols Institute, San Juan Capistrano, CA, USA
512 - Gender Differences in the Response to Influenza in Long-Chain Acyl-coA Dehydrogenase Knockout Mice
Eric Goetzman, Apurva Shinde, Jiadi Luo, Sivakama Bharathi, and Jieru Wang
University of Pittsburgh, Pittsburgh, PA, USA
The role of the fatty acid oxidation enzyme long-chain acyl-CoA dehydrogenase (LCAD) in humans is not understood. We previously showed that LCAD is expressed in human alveolar type 2 pneumocytes and LCAD knockout mice have altered breathing mechanics. Here, we hypothesized that LCAD knockout mice would be susceptible to influenza infection. Surprisingly, there was a gender difference in the response to influenza. Male LCAD knockout mice did not differ from their wild-type counterparts in terms of lung histology, viral titer, weight loss, or blood glucose following influenza infection. Influenza was associated with severe hypoglycemia regardless of genotype. Female LCAD knockout mice, however, were more sensitive to influenza with greater weight loss and poorer survival than wild-type females. Again, hypoglycemia was severe and similar in both genotypes, as were lung histology and viral titers. Female LCAD knockout mice did have higher blood lactate levels and lower core body temperatures than wild-type controls. We conclude that the cause of influenza-associated mortality in LCAD knockout females was the extreme weight loss rather than the lung infection itself. The degree of weight loss correlated very strongly (R2 = 0.97) with lung histology severity scores in female LCAD knockout mice, but not in wild-type females or in male mice of either genotype.
513 - Health-Related Quality of Life in Patients With Long-Chain Fatty Acid Oxidation Disorders
Suzan Knottnerus1, Jeannette Bleeker2, Peter Van Hasselt2, Frits Wijburg1, and Gepke Visser2
1Academic Medical Centre, Amsterdam, the Netherlands
2Wilhelmina Kinderziekenhuis, Utrecht, the Netherlands
514 - Ketolysis Defect, Biochemical Peculiarities for Diagnosis in a 4-Year-Old Child
Romana Vulturar1, Alina Nicolescu2, Laura Bodea3, Tudor Pop4, and Calin Deleanu5
1Univ. of Medicine and Pharmacy from Cluj-Napoca, Cognitive Neuroscience Laboratory, Univ Babes-Bolya, Cluj-Napoca, Romania
2Inst. of Macromolecular Chemistry, Iasi, Romania
3Children Clinical Hospital Cluj, Cluj-Napoca, Romania
4Children Clinical Hospital, Cluj-Napoca, Romania
5Institude of Biochemistry, Romanian Academy, Bucharest, Romania
The emerging field of metabolomics, in which a large number of small-molecule metabolites are detected quantitatively in a single step, promises immense potential for early-diagnosis, monitoring, and understanding the pathogenesis of many diseases. The clinical/ biochemical findings in some inborn errors of metabolism (IEM) are often nonspecific; an early differential diagnosis made in a single urinary sample it gives an important advantage. We present our results and the utility of the NMR spectroscopy method for rapid diagnosis and follow up in a ketolysis defect with high ketones in urine, very high lactic acidosis (in urine lactic acid 86.8546 mmol/mol creatinine). The values for urinary ketones were: 3-hydroxybutiric aciduria (40.4284 mmol/mol creatinine), acetoacetic acid (8.6645 mmol/mol creatinine), acetone (3.9781 mmol/mol creatinine) and have been identified in a 4 years old girl with two acute episodes of hypoglycemia during fasting due to intercurrent viral infections. The level of excretion of the metabolites in this disorder has been well within the range of NMR detection (Bruker Avance 400 MHz-Spectrometer). In the critical care setting, IEM that were not diagnosed through the neonatal screening should be considered as cause of acute neurologic, hepatic/ renal decline, rapid diagnosis being essential. We demonstrate the effective use of NMR-spectroscopic-profiles of urine in differential diagnosis in emergency situations, and the possibility of follow up, as well.
515 - How can we evaluate heart manifestations in Fatty acid oxidation disorders (FAO-disorders)?
Patrícia Pinto1, Patricia Janeiro2, Mónica Rebelo3, Laura Vilarinho4, Isabel Tavares de Almeida5, and Ana Gaspar2
1Pediatric Department, Chln, Hospital de Santa Maria, Lisbon, Portugal
2Metabolic Diseases Unit, Pediatric Department, Chln, Hospital de Santa Maria, Lisbon, Portugal
3Pediatric Cardiology Unit, Chln, Hospital de Santa Maria, Lisbon, Portugal
4Newborn Screening, Met&Ge Unit, Human Genetics Depart., Dr. Ricardo Jorge National Inst. Of Health, Porto, Portugal
5Met&Ge, Imed.Ulisboa, Faculdade de Farmácia, Ulisboa, Lisbon, Portugal
516 - The Biochemical Basis for Overlap of Clinical Features of LCHAD/TFP Deficiency With Mitochondrial Respiratory Chain Defects: Implications for New Therapeutic Approaches
Areeg El-Gharbawy1, Bianca Seminotti1, Shrabani Basu1, Genevieve Sparagna2, Grant Hatch3, Anuradha Karunanidhi1, Al-Walid Mohsen1, Jerry Vockley1, and Yudong Wang1
1Department of Pediatrics, Division of Medical Genetics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
2Department of Medicine, University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado, Denver, CO, USA
3Department of Biochemistry, University of Manitoba, Winnipeg, Manitoba, Canada, Manitoba, Canada
517 - Multiple Acyl-coA dehydrogenase Deficiency (MADD): Twenty Years of Follow Up, Long Term Treatment, and Outcomes
Consuelo Durand1, Delfina Marchione1, Silvana Lavorgna1, Jose Abdenur2, and Andrea Schenone1
1Laboratorio Chamoles, C.A.B.A., Argentina
2Division of Metabolic Disorders, Choc Children’s, Orange, CA, USA
518 - A Rare Cause of Newborn Hypoglycemia and Hyperammonemia: CACT Deficiency
Aynur Kucukcongar Yavas, Özlem Ünal, and Mehmet Gunduz
Child Health and Diseases Hematology Oncology Education and Training Hospital, Ankara, Turkey
Carnitine-acylcarnitine translocase (CACT) deficiency is a rare autosomal recessive disease in the mitochondrial transport of long-chain fatty acids which represent an energy production insufficiency during prolonged fasting, febrile illness, or increased muscular activity. CACT deficiency is caused by mutations of the SLC25A20 gene. Most patients developed severe metabolic decompensation in the neonatal period and died in infancy despite aggressive treatment.
519 - Beta-Oxidation Defect of Fatty Acids (FAO defects): Long-Chain 3-Hydroxyacyl-CoA Dehydrogenase Deficiency as a Cause of Non-Ketotic Hypoglycemia: A Case Report
Ana Cecilia Bonilla Suárez, Sheyla Alegre Pariona, Lilia Rojas Coronel, Gaudi Lozano Rojas, Luciana Scerpella Crespo, Magali Mendiola, Mónica Angulo Barranca, Nataly Aramburú Miranda, Marco Morales-Acosta, and Milagros Dueñas-Roque
Hospital Nacional Edgardo Rebagliati Martins, Lima, Peru
O) Mitochondrial Disorders: Nuclear Encoded, Disorders of Pyruvate Metabolism (520 to 551)
520 - Severe Brain Malformations in an Infant With Pyruvate Dehydrogenase Deficiency and Down Syndrome
Cristel Chapel-Crespo and Pankaj Prasun
Icahn School of Medical at Mount Sinai Hospital, New York, NY, USA
A female infant born to a 39-year-old G3P2 at 38 weeks gestation with poor tone, respiratory failure, and dysmorphic features. Postnatally, she was diagnosed with congenital heart disease and Trisomy 21 (T21). In addition, she developed persistent lactic acidosis, which in combination with the severe clinical picture was not consistent with T21. This lead to the suspicion of pyruvate dehydrogenase deficiency (PDH), which was later confirmed by molecular testing (c.858_861dupTTAC). Subsequently, a brain MRI revealed marked reduction in cerebral volume and multicystic encephalomalacia. Treatment with thiamine and carnitine supplementation and low carbohydrate diet was implemented with subsequent stabilization of lactate levels. These findings have not previously been reported in patients with either PDH deficiency or T21, and most likely represent a brain insult due to the combination of both conditions. Therefore, this is the first known case of a patient with both PDH deficiency and T21. Finally, it is important to always consider alternate etiologies when the clinical picture is not consistent with a specific disorder.
521 - Childhood-Onset Neurodegeneration Secondary to Absence of the Autophagy Adaptor SQSTM1/p62: Case Report
Mara Lucia Santos, Cristiane Benincá, Daniel Valle, Ana Gabriela Bicalho, Fernanda Colomé, Leticia Kabashima, Joselainy Galeazzi, Paula Gomes, Bruno Telles, and Vaneisse Monteiro
Hospital Pequeno Príncipe, Curitiba, PR, Brazil
We present a 4 years old girl, from a non-consanguineous family. She has no family history of neurological disorders and no significant past medical history. At 2 years old, the patient began cerebellar ataxia, tremors, abnormality in gait, and speech regression. The patients progress with unsteadiness of gait, coordination problems, cognitive decline, refractory seizures, and generalized dystonia. An appendicular spasticity was observed at 3 years old. Brain magnetic resonance showed mild cerebellar atrophy, progressing with generalized cerebral atrophy. Exome sequencing identified mutation in the SQSTM1. SQSTM1 (sequestosome 1), also known as p62, encodes a multidomain scaffolding protein involved in various key cellular processes, including the removal of damaged mitochondria by its function as a selective autophagy receptor. Nine cases were described previously in literature presenting with gait abnormalities, ataxia mostly of the upper limbs, dysarthria, dystonia, vertical gaze palsy and mild cognitive decline. The course was remarkably similar in all described affected individuals. This patient is the youngest person describe with absence of the autophagy adaptor SQSTM1/p62. Our findings expand the SQSTM1-associated phenotypic spectrum and lend further support to the concept of disturbed selective autophagy pathways in neurodegenerative diseases.
522 - Biallelic Mutations in the TRAK1 Disrupt Mitochondrial Motility and Cause Fatal Encephalopathy
Yair Anikster1, Ben Pode-Shakked2, Ortal Barel3, Carlos Ferreira4, Douglas C. Wallace5, William A. Gahl4, David M. Eckmann6, Bruria Ben-Zeev2, May Christine Malicdan7
1Edmond and Lily Safra Children’s Hospital, Sheba Medical Center, Sackler Faculty of Medicine, Tel-Hashomer, Israel
2Edmond and Lily Safra Children’s Hospital, Sheba Medical Center, Sackler Faculty of Medicine., Tel-Hashomer, Israel;
3Sheba Cancer Research Center, Sheba Medical Center, Tel-Hashomer, Israel
4Medical Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
5Center for Mitochondrial and Epigenomic Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
6Department of Bioengineering, University of Pennsylvania, Philadelphia, PA USA
7Nih Undiagnosed Diseases Program, Nigari, National Institutes of Health, Bethesda, MD USA
Cellular distribution and dynamics of mitochondria are regulated by several motor proteins and a microtubule network. In neurons, mitochondrial trafficking is crucial because of high energy needs and calcium ion buffering along axons to synapses during neurotransmission. The trafficking kinesin proteins (TRAKs) are well characterized for their role in lysosomal and mitochondrial trafficking in cells, especially neurons. Variants in the mouse orthologue of human TRAK1 (hyrt mutant mice) have been associated with low levels of γ-aminobutyric acid type A (GABAA) receptors, and hence deficiency of GABA-mediated neural inhibition, in the brain of hypertonic mice. Using whole exome sequencing, we identified homozygous truncating variants in TRAK1 (NM_001042646: c.287-2A>C), in lethal encephalopathic patients from three unrelated families. The pathogenic variant results in aberrant splicing and significantly reduced gene expression at both the RNA and protein levels. In comparison with normal cells, TRAK1 deficient fibroblasts showed irregular mitochondrial distribution, altered mitochondrial motility, reduced mitochondrial membrane potential, and diminished mitochondrial respiration. This study confirms the role of TRAK1 in mitochondrial dynamics and constitutes the first report of this gene in association with a severe neurodevelopmental disorder.
523 - Heterogeneous Forms of Nuclear Encoded Mitochondrial Diseases in Children
Ekaterina Nikolaeva and Maria Yablonskaya
Research and Clinical Institute Of Pediatrics Named After Yuri Veltischev Of The Pirogov University, Moscow, Russia
524 - MitoEpilepsy Map: A Novel Computational Resource for the Diagnosis of Mitochondrial Epilepsy
Joyeeta Rahman1, Alberto Noronha2, Ines Thiele2, and Shamima Rahman1
1Ucl Great Ormond Street Institute of Child Health, London, United Kingdom
2Luxembourg Centre for Systems Biomedicine, Esch-Sur-Alzette, Luxembourg
525 - Application of Next Generation Sequencing to Mitochondrial Disorders: From Clarifying the Pathophysiology to Creating the New Therapy
Akira Ohtake1, Kei Murayama2, and Yasushi Okazaki3
1Department of Pediatrics, Saitama Medical University, Saitama, Japan
2Department of Metabolism, Chiba Children’s Hospital, Chiba, Japan
3Research Center for Genomic Medicine, Saitama Medical University, Saitama, Japan
526 - Heterogeneous Forms of Nuclear Encoded Mitochondrial Diseases in Children
Ekaterina Nikolaeva1, Maria Yablonskaya1, Polina Tsygankova2, Tatiana Krylova2, Tatiana Proshlyakova2, Petr Shatalov1, and Malvina Kharabadze1
1Research and Clinical Institute of Pediatrics Named After Yuri Veltischev of the Pirogov University, Moscow, Russia
2Research Centre for Medical Genetics of the Russian Academy of Sciences, Moscow, Russia
527 - Clinical Features and Natural History of Childhood Onset POLG Disease
Shamima Rahman1, Omar Hikmat2, Charalampos Tzoulis3, Wui K. Chong4, Latifa Chentouf1, Claus Klingenberg5, Carl Fratter6, Lucinda Carr7, Prab Prabhakar7, Nandhini Kumaraguru8, Paul Gissen9, Helen Cross7, Thomas Jacques10, Jan-Willem Taanman11, and Laurence Bindoff3
1Mitochondrial Research Group, Ucl Great Ormond Street Institute of Child Health, London, United Kingdom
2Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
3Department of Neurology, Haukeland University Hospital, Bergen, Norway
4Department of Radiology, Great Ormond Street Hospital for Children Nhs Foundation Trust, London, United Kingdom
5Department of Paediatric and Adolescent Medicine, University Hospital of North Norway, Tromso, Norway
6Oxford Medical Genetics Laboratories, Oxford University Hospitals Nhs Foundation Trust, Oxford, United Kingdom
7Department of Neurology, Great Ormond Street Hospital for Children Nhs Foundation Trust, London, United Kingdom
8Department of Paediatrics, Nottingham University Hospital Nhs Trust, Nottingham, United Kingdom
9Metabolic Unit, Great Ormond Street Hospital for Children Nhs Foundation Trust, London, United Kingdom
10Department of Histopathology, Great Ormond Street Hospital for Children Nhs Foundation Trust, London, United Kingdom
11Department of Clinical Neurosciences, Ucl Institute of Neurology, London, United Kingdom
528 - Mitochondrial Dysfunction is Comorbid With Susceptibility to Post-Traumatic Stress Disorder in Mice
Graeme Preston1, Tim Emmerzaal2, Faisal Kirdar1, Eva Morava1, and Tamas Kozicz1
1Tulane University School of Medicine, New Orleans, FL, USA
2Radboud University Medical Centre, Nijmegen, the Netherlands
Psychopathology is frequently associated with mitochondrial dysfunction in patients. Post-traumatic stress disorder (PTSD) is a debilitating psychiatric disorder that affects millions of people worldwide. Induced by exposure to a traumatic event, the presentation of the disease in terms of duration and symptomatology is highly heterogenous, and the severity of the inducing trauma does not predict the severity of the disorder. This suggests the possibility of an underlying genetic metabolic factor. We therefore investigated whether susceptibility to PTSD is associated with mitochondrial dysfunction. We exposed 48 wildtype male mice of the FVB.129P2 (“sighted” FVB) background to a PTSD-induction paradigm previously shown to reliably induce PTSD-like symptomatology with a similar presentation to that of PTSD in humans. The inducing trauma was inescapable electric foot shock, administered in two decontextualized sessions over two consecutive days. PTSD-susceptible animals were diagnosed through a series of behavioral tests to identify some physical symptoms of PTSD: hyperarousal, hypervigilance, and sleep cycle disruption. Those 12 animals most and least clearly displaying PTSD-like symptomatology were identified, brain tissue was collected, and mitochondria were isolated. The activities of the electron transport chain (ETC) complexes I, II, III and IV, as well as citrate synthase, were measured spectrophotometric assay using a Konelab autoanalyzer to determine mitochondrial activity and density, respectively. Comparing, ETC activity and mitochondrial density to PTSD-symptomatology reveals a statistically-significant inverse relationship between PTSD susceptibility and mitochondrial capacity (P = .016). Our results indicate that susceptibility to PTSD in mice is comorbid with reduced mitochondrial capacity. To demonstrate that mitochondrial dysfunction is sufficient to induce PTSD susceptibility, we are currently inducing PTSD in a strain of transgenic mice with genetically-induced suboptimal mitochondrial function, and assaying for a concordant increase in PTSD susceptibility. We are also investigating how reduced mitochondrial capacity affects activation of large scale brain networks and endocrine functions involved in stress response.
529 - CMPK2, a Mitochondrial Enzyme in the Nucleotide Salvage Pathway, Might be Related to a MNGIE-Like Phenotype
Francis Rossignol1, Isabelle de Bie2, Valérie Marchand1, Christophe Faure1, Cam-Tu Emilie Nguyen1, Manon Bouchard1, Sylvie Lebrun1, Philippe Campeau1, Grant Mitchell1, and Catherine Brunel-Guitton1
1Chu Sainte-Justine, Université de Montréal, Montréal, Canada
2Montreal Children's Hospital, Mcgill University, Montréal, Canada
530 - Mutations in the NDUFAF4 Impairs Mitochondrial Supercomplexes Formation and Causes Dysmorphia, Cardiomyopathy, and 3-Methylglutaconic Aciduria
Frederic Tort1, Olatz Ugarteburu1, Maria Teresa Garcia-Silva2, Pablo Sanjurjo3, Luis Aldámiz-Echevarria3, Judit Garcia-Villoria1, Xenia Ferrer1, Angela Arias1, Paz Briones1, Antonia Ribes1
1Hospital Clinic de Barcelona And Ciberer, Barcelona, Spain
2Hospital 12 de Octubre, Madrid, Spain
3Hospital de Cruces, Bilbao, Spain
We present two siblings with convulsions, irritability, facial dysmorphia, leukodystrophy and hypertrophic cardiomyopathy since the neonatal period. Metabolic studies showed high plasma levels of lactate and α-alanine. The organic acid profile showed increased excretion of lactate, succinate, fumarate, 2-ketoglutarate and 3-methylglutaconate (3-MG). The excretion of 3-MG together with the dysmorphic features made the rationale for the analysis of possible mutations in genes associated to 3-MGA-uria, which were excluded using a self-designed gene panel. Whole-exome sequencing identified a homozygous nonsense mutation in the NDUFAF4 (c.558G>T; p.Glu160*), an assembly factor of the mitochondrial respiratory complex I. BN-PAGE performed in patient’s fibroblasts showed an isolated deficiency in the assembly of complex I, that was consistent with the genetic data. Since the first description in 2009 (Saada et al. Am J Hum Genet. 2009) no other patients with NDUFAF4 mutations have been reported. Moreover, the pathophysiological mechanisms underlying NDUFAF4 deficiency have not been well documented so far. To further characterize this disorder, we have analyzed mitochondrial membrane potential by TMRM labeling and demonstrated a severe loss of membrane potential in patient’ cells. We have also studied the impact of NDUFAF4 deficiency in the mitochondrial function by analyzing the formation and the activity of respiratory chain supercomplexes. We have demonstrated a complete absence of the higher molecular-weight forms of respiratory supercomplexes in NDUFAF4 patient’ cells together with an abnormal accumulation of complexes containing exclusively CIII and CIV. Our results provide new insights on the pathophysiological mechanisms underlying NDUFAF4 deficiency and highlight the importance of precise biochemical and functional characterization for the elucidation of the genetic causes of mitochondrial energy metabolism disorders using next generation sequencing.
531 - A Lethal Neonatal Phenotype of Mitochondrial Short-Chain Enoyl-CoA Hydratase-1 Deficiency
Fuad Al Mutairi
King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
Short-chain enoyl-CoA hydratase (SCEH) is a mitochondrial enzyme involved in the oxidation of fatty acids and the catabolic pathway of valine and, to a lesser extent, isoleucine. Deficiency of this enzyme was recently shown to cause an early childhood Leigh syndrome phenotype. The few reported patients were compound heterozygotes for two missense or missense with truncating variants in the ECHS1 that encodes SCEH. We describe two siblings with severe refractory lactic acidosis and death within the first 2 days of life. Following negative clinical whole-exome and whole-genome sequencing, we resorted to autozygome/exome analysis on research basis and identified a homozygous splice site mutation (c.88+5G>A) in the two cases. Analysis of cDNA confirmed complete replacement of the normal transcript with an aberrant transcript (r.88_89ins 88+1_88+11) predicting premature truncation of the protein [p.(Ala31Glufs*23)]. Furthermore, quantitative reverse transcriptase polymerase chain reaction (RTPCR) showed marked reduction in ECHS1, most likely nonsense-mediated decay (NMD)-mediated. This is the first report of homozygosity for a truncating mutation in the ECHS1, which may explain the severe phenotype. Our report highlights the need to consider SCEH deficiency in patients with lethal neonatal lactic acidosis, and the potentially limited sensitivity of untargeted genomic sequencing toward noncanonical splicing mutations, which may explain at least some of the “negative” cases on clinical exome/genome sequencing.
532 - Developing a Tissue-Specific ACAD9 Deficient Mouse Model Using Cre-lox Recombination
Andrew Sinsheimer1, Lina Ghaloul-Gonzalez2, Areeg El-Gharbawy2, Al-Walid Mohsen2, Anuradha Karunanidhi2, Eric Goetzman2, Robert Nicholls2, Yijen Wu2, and Jerry Vockley2
1Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
2Division of Medical Genetics, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
533 - Extending the Phenotypic Spectrum of Sengers Syndrome: Severe Case Presenting With Cardiogenic Shock and Synthetic Liver Dysfunction in a Newborn
Eyby Leon1, David Beck2, Nickie Andescavage1, and Kristina Cusmano-Ozog1
1Children’s National Health System, Washington, DC, USA
2National Institute of Health, Bethesda, MD, USA
Sengers syndrome is a rare autosomal recessive mitochondrial disease characterized by lactic acidosis, hypertrophic cardiomyopathy and bilateral cataracts. It is caused by mutations in the AGK gene which codes for acylglycerol kinase, a mitochondrial transmembrane enzyme that can participate in phospholipid synthesis or act as signaling molecule regulating a number of cell processes including the OXPHOS. Sengers syndrome has two distinct clinical forms, a severe neonatal form and a later onset form with survival into the fourth decade of life. To date there have been less than thirty molecularly diagnosed patients with Sengers syndrome, with the majority consisting of later onset disease. We present here a case of neonatal demise within the first day of life, found to have a severe lactic acidosis, in the setting of both chorioamnionitis and cardiomyopathy with signs of cardiogenic shock. Clinical exam was notable for profound encephalopathy and bilateral opacification of the corneas. Metabolic labs were concerning for significantly elevated lactate refractory to resuscitation, and a lactate to pyruvate ratio of 91 suggestive of mitochondrial disease. Low albumin, total protein, and prolonged PT, PTT with normal bilirubin and elevated transaminases were noted. Plasma amino acids showed elevation of methionine, phenylalanine, and branched chain amino acids, indicating liver dysfunction and catabolism. The patient did not receive TPN. Blood, urine, and CSF cultures were negative. Given metabolic results and consanguineous family history, a nuclear mitochondrial gene panel was sent revealing a homozygous pathogenic variant in AGK, c.979A>T p.K327*. A novel finding in our patient was synthetic liver dysfunction which has not been previously noted in Sengers syndrome. To our knowledge, there is only one patient reported in the literature with primary liver involvement showing cytosolic granules in liver cells after autopsy. Some authors have even suggested that the neonatal form of Sengers syndrome should be described as a mitochondrial encephalomyopathy due to CNS involvement but there is no mention of liver compromise which is not unusual to find in mitochondrial disorders. We present a severe case of Sengers syndrome reported with novel characteristics. This case highlights the importance of a wide differential diagnosis for congenital lactic acidosis even in cases with apparent common neonatal conditions.
534 - Novel Role for Store-Operated Calcium Entry in Mitochondrial Gene Expression, Energy Production, and Beta-Oxidation
Mate Maus1, Mario Cuk2, Bindi Patel3, Jayson Lian1, Mireille Ouimet4, Ulrike Kaufmann1, Jun Yang1, Rita Horvath5, Hue-Tran Hornig-Do5, Zofia Chrzanowska-Lightowlers5, Kathryn Moore4, Ana Maria Cuervo3, and Stefan Feske1
1Department of Pathology, New York University School of Medicine, New York, NY, USA
2Department of Pediatrics, Zagreb University Hospital Centre and School of Medicine, Zagreb, Croatia
3Department of Developmental and Molecular Biology, Albert Einstein College of Medicine, New York, NY, USA
4Department of Medicine, New York University School of Medicine, New York, NY, USA
5Wellcome Trust Centre For Mitochondrial Research, Institute of Neuroscience, Newcastle University, New Castle Upon Tyne, United Kingdom
Store-operated Ca2+entry (SOCE) is a pathway for increasing intracellular Ca2+ levels regulated by stromal interaction molecule 1 (STIM1), STIM2, and the Ca2+ channel ORAI1. SOCE-deficient patients suffer from
535 - Next Generation Sequencing Improves Mitochondrial Diseases Diagnosis
Celia Nogueira1, Cristina Pereira1, Lisbeth Silva1, Luis Vieira2, Elisa Leão Teles3, E Rodrigues3, T Campos3, Patricia Janeiro4, Cláudia Dias da Costa4, Ana Gaspar4, Juliette Dupont4, Gabriela Soares5, Anabela Bandeira5, Esmeralda Martins5, Marina Magalhães5, Sílvia Sequeira6, Jose Pedro Vieira6, Helena Santos7, and Laura Vilarinho1
1National Institute of Health, Insa, Porto, Portugal
2National Institute of Health, Insa, Lisboa, Portugal
3Centro Hospitalar São João, Epe, Porto, Portugal
4Centro Hospitalar Lisboa Norte, Epe, Lisboa, Portugal
5Centro Hospitalar e Universitário do Porto, Epe, Porto, Portugal
6Centro Hospitalar Lisboa Central, Epe, Lisboa, Portugal
7Centro Hospitalar de Vila Nova de Gaia, Epe, Porto, Portugal
536 - Novel Hemizygous Mutation of TAZ Gene in a Boy With Atypical Barth Syndrome
Loreta Cimbalistiene1, Birute Burnyte1, Vilija Cerniauskiene2, Ausra Morkuniene1, Laima Ambrozaityte1, Ramunas Janavicius3, and Algirdas Utkus1
1Department of Human and Medical Genetics, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
2Childrens Hospital, Affiliate of Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
3Department of Molecular and Regenerative Medicine, Hematology, Oncology and Transfusion Medicine, Vilnius, Lithuania
537 - Diagnosis of Mitochondrial Disorders: The Perspective of a Biochemical-Genetics Testing Laboratory
Irene Bravo-Alonso, Ana I Vega, Rosa Navarrete, David Rubio-Mangas, Begoña Merinero, Celia Pérez-Cerdá, Magdalena Ugarte, Belen Pérez, and Pilar Rodriguez-Pombo
Centro de Diagnóstico de Enfermedades Moleculares. Universidad Autonoma de Madrid, Madrid, Spain
The irruption of high-throughput sequencing techniques in the genetic analysis of human Mendelian diseases has dramatically improved the rate of diagnostic success of diseases with complex and expanding spectrums of clinical phenotypes and genotypes such as the primary mitochondrial disorders. The 55 patients (males and females) included in this study are a representative sample of the broad spectrum of symptoms of the patients’ population referred to our center from different Hospitals with clinical suspicion of congenital lactic acidosis (CLA), mitochondrial disorder (MD), or even of a less specific -inherited metabolic disorder-. Most of them showed a metabolite profile suggestive of CLA or MD with elevated lactate and/or alanine in blood, and urine and all were analyzed according to our in house genetic screen cascade. The framework included a first analysis of nuclear genes by using a Mendelioma massive parallel sequencing (MPS), and a subsequent entire mitochondrial genome (mtWGS) by MPS. Rare variants were filtered and prioritized, and for those patients with only one mutation identified in strong nuclear candidate genes, a functional genomic study based in a case-by case analysis of aberrant transcript present in patients’ cells and absent in control samples was applied. For mtDNA variants, we targeted those changes reported in MITOMAP. With this approach, we identified the genetic cause in 24 out of the 55 patients analyzed. Of these, 21 patients harbored 30 disease-causing changes, 12 of them news, in 16 known nuclear genes. Other three patients carried known point mutations in mtDNA: G8719A (MT-ATP6), T10158C (MT-ND3) and G13513A (MT-ND5). In silico predictions supported the pathogenic role in each case. Segregation analysis in parents’ DNA confirmed their carrier condition. Finally, cDNA analysis of other three patients with only one change detected in GFM1, ARALAR or MRPL3 concluded with the identification of the deep intronic c.689+908G>A in GFM1 gene and left undiagnosed the other two. Up to now, our pipeline has allowed to diagnose a 44% of the patients analyzed. Beyond the use of genetic diagnosis strategies based in whole exome or RNA sequencing, the identification of specific metabolic signatures lying downstream of the primary mitochondrial lesions and the unification of criteria to classify clinical symptoms, will contribute to improve the MD diagnosis and treatment. PI12/02078; PI16/00573; MINECO-FEDER. Fundación Isabel Gemio
538 - Novel Mutation in the MT-ND5 Gene as the Cause of a Multisystemic Mitochondrial Disorder—Expanding the Phenotype
Sílvia Sequeira1, Cristina Pereira2, Celia Nogueira2, Lisbeth Silva2, Manuela Grazina3, Lurdes Lopes4, Telma Francisco5, Paula Kjöllerström6, Margarida Guimarães7, Sandra Jacinto8, and Laura Vilarinho2
1Metabolic Unit, Hospital de Dona Estefânia, Chlc, Lisbon, Portugal
2Human Genetics Department, National Institute of Health, Insa, Oporto, Portugal
3Center For Neuroscience and Cell Biology. University of Coimbra, Coimbra, Portugal
4Endocrinology Unit, Hospital de Dona Estefânia, Chlc, Lisbon, Portugal
5Nephrology Unit, Hospital de Dona Estefânia, Chlc, Lisbon, Portugal
6Hematology Unit, Hospital de Dona Estefânia, Chlc, Lisbon, Portugal
7Pathology Department, Hospital de Dona Estefânia, Chlc, Lisbon, Portugal
8Neuropaediatric Unit, Hospital de Dona Estefânia, Chlc, Lisbon, Portugal
539 - Mitochondrial Cavitating Leukoencephalopathy: Phenotypes and Novel Mutations in the NDUFA5 and APOPT1
Inés Denzler1, Clarisa Maxit1, Alejandra Gonzalez1, Laura de Rosa1, María Vaccarezza1, Guillermo Agosta1, Soledad Kleppe2, and Marjo Van Der Knaap3
1Department of Child Neurology. Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
2Department of Pediatrics. Hospital Italiano de Buenos Aires., Buenos Aires, Argentina
3Department of Child Neurology. Vu University Medical Center, Amsterdam, the Netherlands
540 - NAD(P)HX Dehydratase (NAXD) Deficiency: A Novel Neurodegenerative Disorder Exacerbated by Febrile Illnesses
Nicole Van Bergen1, Yiran Guo2, Nicole Paczia3, Julia Becker3, Sian Ellard4, Carolyn Ellaway5, Peter Procopis5, Julia Rankin4, Julia Baptista4, Esther Meyer4, Garan Jones4, Tessa Homfray6, Hakon Hakonarson2, David Thorburn1, Carole Linster3, and John Christodoulou1
1Murdoch Children’s Research Institute, Melbourne, Australia
2Center for Applied Genomics (Cag) at The Children’s Hospital of Philadelphia (Chop), Philadelphia, PA, USA
3University of Luxembourg, Luxembourg City, Luxembourg
4University of Exeter Medical School, Exeter, United Kingdom
5Children’s Hospital at Westmead, Sydney, Australia
6St George’s Hospital, Royal Brompton Hospital, London, United Kingdom
541 - The Utility of Quantitative Proteomic and RNA Analyses to Aid in Diagnosis of Exome-Unsolved Cases and in the Identification and Characterization of Novel Disease Genes
David Thorburn1, Ann Frazier1, David Stroud2, Nicole Lake1, Alison Compton1, Shalini Thirukeswaran1, Michael Ryan2, Lambert Van Den Heuvel3, Jan Smeitink3, Akira Ohtake4, Yasushi Okazaki4, Anne Lombes5, Ian Holt6, and Antonella Spinazzola7
1Murdoch Children’s Research Institute, Melbourne, Australia
2Monash University, Melbourne, Australia
3Radboud University Medical Center, Nijmegen, the Netherlands
4Saitama Medical University, Saitama, Japan
5Universite' Paris-Descartes, Paris, France
6Biodonostia Health Research Institute, San Sebastian, Spain
7Inst. of Neurology, University College London, London, United Kingdom
542 - TMEM70 Mutation in an Turkish Infant With Volvulus, Hypertrophic Cardiomyopathy, Wolff Parkinson White Syndrome, Hypotonia, and Dysmorphism
Neslihan Mungan1, Fatma Derya Bulut1, Fadli Demir2, Sebile Kilavuz1, Deniz Kor1, Berna Seker Yilmaz1, Şakir Altunbaşak3, Özden Özgür Horoz4, Sevcan Erdem2, and Nazan Özbarlas2
1Div Ped Metabolism, Çukurova University, Adana, Turkey
2Div Ped Cardiology, Çukurova University, Adana, Turkey
3Div Ped Neurology, Çukurova University, Adana, Turkey
4Div Ped Intensive Care Unit, Çukurova University, Adana, Turkey
543 - Molecular and Clinical Spectra of FBXL4 Deficiency
Ayman El-Hattab1, Hongzheng Dai2, Mohammed Almannai2, Julia Wang2, Lee-Jun Wong2
1Tawam, Al-Ain, United Arab Emirates
2Baylor College of Medicine, Houston, TX, USA
F-box and leucine-rich repeat protein 4 (FBXL4) is a mitochondrial protein that plays significant roles in mitochondrial bioenergetics, mitochondrial DNA (mtDNA) maintenance, and mitochondrial dynamics. Biallelic FBXL4 pathogenic variants have been associated with an encephalopathic mtDNA maintenance defect (MDMD) syndrome characterized by early onset lactic acidemia, developmental delay, hypotonia, feeding difficulties, growth failure with microcephaly, hyperammonemia, seizures, cardiomyopathy, liver dysfunction, recurrent infections, variable distinctive facial features, white matter abnormalities and cerebral atrophy in neuroimaging, combined deficiencies of multiple electron transport complexes, and mtDNA depletion. Since its initial description in 2013, 36 different pathogenic variants in FBXL4 have been reported in 50 affected individuals. Herein we present 37 additional affected individuals and 11 previously unreported pathogenic variants. We summarize the clinical features of the total 87 individuals with FBXL4-related MDMD, review FBXL4 structure and function, map the 47 pathogenic variants onto the gene structure to assess the variants distribution, and investigate the genotype-phenotype correlation. Finally, we provide future directions to understand the disease mechanism and identify treatment strategies.
544 - Infantile Mitochondrial DNA Depletion Syndrome due to RRM2B mutation: A Natural History Study of Four New Cases
Nandaki Keshavan1, François Feillet2, Natalie Hauser3, Mark Sharrard4, Carl Fratter5, Conrad Smith5, Giulia Barci6, Zahra Assouline6, Agnès Rötig7, and Shamima Rahman8
1Department of Paediatric Metabolic Medicine, Great Ormond Street Hospital Nhs Trust, London, United Kingdom
2Reference Centre for Inherited Metabolic Diseases, Nancy, France
3Inova Fairfax Hospital, Fairfax, VA, USA
4Sheffield Children’s NHS Foundation Trust, Sheffield, United Kingdom
5oxford Medical Genetics Laboratories, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
6Department of Genetics, Necker Hospital—Sick Children, Paris, France
7Imagine Institute, Paris, France
8Ucl Great Ormond Street Institute of Child Health, London, United Kingdom
545 - Mitochondrial Disorders Associated With High Percentage of DNA Damage in Infantile—Pediatrics Patients Compared To Adult Patients—A Pilot Study From North India
Somesh Kumar1, Arun Kumar2, Avinash Lomash1, Mohd. Faruq3, and Seema Kapoor1
1Maulana Azad Medical College, New Delhi, India
2Division of Radiation Biosciences, Inmas, New Delhi, India
3Csir-Igib, Mall Road, New Delhi, India
546 - Whether a Frequency of p.E140 K Substitution in the SCO2 Gene is Underestimated in Children With Infantile Mitochondrial Encephalomyopathy?
Yulia Itkis1, Igor Bychkov1, Polina Tsygankova1, Svetlana Mikhailova2, Natalia Pichkur3, and Ekaterina Zacharova1
1Fsbi Research Centre for Medical Genetics, Moscow, Russia
2Fsbi “Russian Child Clinical Hospital” of Russian Ministry of Health, Moscow, Russia
3The National Children’s Specialized Hospital “Okhmatdet”, Kiev, Ukraine
Mitochondrial disorders present a heterogeneous group of inherited disorders with wide clinical manifestations. As age of onset and symptoms considerably vary, NGS technologies become the main diagnostic approach for searching a genetic cause of mitochondrial pathology and could be effective to expand knowledge about genotypic and phenotypic spectrum in this group of diseases. During the last 2 years we apply a target sequencing of mitochondrial nuclear genes using NGS technology on IonTorrent PGM to define a molecular defect in patients suspected for mitochondrial disease. Here we present a group of 8 patients (6 from Russia, 2 from Ukraine) with revealed homozygous c.418G>A (p.E140 K) mutation in the SCO2 gene with a clinical diagnosis of infantile mitochondrial encephalomyopathy/ Leigh syndrome. These children have varieties in disease manifestations but there are some important common clinical features: progressive psychomotor development delay, acute hypotrophy, muscle hypotonia with decreased reflexes, respiratory insufficiency and stridor, oculomotor abnormalities, lactic acidosis and first symptoms developed at age 2-8 months. Our data demonstrates that p.E140 K mutation in the SCO2 gene is a second frequent cause of infantile mitochondrial encephalomyopathies after 2 bp deletion c.845_846del in SURF1 gene among Russian and Ukranian patients with nuclear DNA mutations. So far, we have been diagnosed about 60 SURF1 patients with c.845_846del, however all of them have been revealed on a first step of routine diagnostic by SSCP analysis but simple methods have not been applied for searching frequent mutations in the SCO2 gene. Interestingly that fist description of this mutation was in 1999 in a patient with fatal cardiomyopathy, however first Russian patient with SCO2 mutation was found in 2015. According to ExAc database for European (non-Finnish) population, the allele frequency of c.845_846del in SURF1 is about 1 per 7000 and the allele frequency of c.418G>A in SCO2 is about 1 per 5500. Therefore, we speculate that contribution of SCO2 gene p.E140 K substitution in infantile mitochondrial encephalomyopathy is underestimated in Russian and Ukranian patients.
547 - Exome Sequencing Reveals Mutations in the Mitochondrial Phosphodiesterase PDE12 in an Infant With Lethal Neonatal Lactic Acidosis
Mariella Simon, Alexander Stover, Shaina Eftekharian, Richard Chang, and Jose Abdenur
Choc Children’s, Orange, CA, USA
The mitochondrial (mt) phosphodiesterase PDE12 removes mt-RNA poly (A) tails, plays a role in mt-RNA turnover and translation and is involved in immune response. Studies to establish the effects of decreased or overexpressed PDE12 suggest species and tissue specific outcomes. In mice, Pde12 knockout results in an embryonic lethal phenotype. No disease has been reported in association with mutations in the PDE12.
548-A Novel ETHE1 Mutation Produces Multifocal Epilepsy and Diffusion Restriction on Brain MRI in Ethylmalonic Encephalopathy
Adriana Isabel Henao López, Carolina Baquero-Montoya, Maria Elsy Sepúlveda-Hincapié, Susana Molina Restrepo, Ana Marverin Correa Varela, Paula Andrea Cañaveral Londoño, Beatriz Helena Beatriz Helena, Felita Restrepo, Sandra Catalina Mesa Restrepo, Sandra Isabel Alzate Vanegas, Catalina Ortiz-Piedrahita, Dora Hernández, Ana Carolina Sierra, Karen Aguirre, Zoila Margarita Insignares, Olga Rincón, María Alejandra Cano Romero, and Ana María Bedoya
Hospital Pablo Tobón Uribe, Medellín, Colombia
Ethylmalonic encephalopathy is a metabolic disorder, in which the neurological involvement is characterized by neurodevelopmental delay and regression, pyramidal and extrapyramidal signs. Brain MRI demonstrates necrotic lesions in deep gray matter structures. Here, we report on a patient with Ethylmalonic encephalopathy with a severe phenotype, which includes multifocal epilepsy and diffusion restriction on brain MRI, who also carried out a novel mutation in the ETHE1. The proband presented with developmental delay, seizures, diarrhea, acrocyanosis and petechiae. The EEG showed multifocal epilepsy. Brain MRI findings included injuries in deep basal ganglia and brain stem with diffusion restriction. The metabolic work-up demonstrated metabolic acidosis and high urine levels of ethylmalonic acid. The molecular analysis showed a novel mutation in the ETHE1. The identification of this novel mutation in the ETHE1 in a proband with a severe neurological involvement which includes multifocal epilepsy and restriction to the diffusion allows to expand the known phenotype of this lethal disorder.
549 - A Novel ETHE1 Mutation Produces Multifocal Epilepsy and Diffusion Restriction on Brain MRI in Ethylmalonic Encephalopathy
Adriana Isabel Henao López, Carolina Baquero-Montoya, Maria Elsy Sepúlveda-Hincapié, Susana Molina Restrepo, Ana Marverin Correa Varela, Paula Andrea Cañaveral Londoño, Beatriz Helena Beatriz Helena, Feliza Restrepo, Sandra Catalina Mesa Restrepo, Sandra Isabel Alzate Vanegas, Catalina Ortiz-Piedrahita, Dora Hernández, Ana Carolina Sierra, Karen Aguirre, Zoila Margarita Insignares, Olga Rincón, María Alejandra Cano Romero, and Ana María Bedoya
Hospital Pablo Tobón Uribe, Medellín, Colombia
Ethylmalonic encephalopathy is a metabolic disorder, in which the neurological involvement is characterized by neurodevelopmental delay and regression, pyramidal and extrapyramidal signs. Brain MRI demonstrates necrotic lesions in deep gray matter structures. Here, we report on a patient with Ethylmalonic encephalopathy with a severe phenotype, which includes multifocal epilepsy and diffusion restriction on brain MRI, who also carried out a novel mutation in ETHE1. The proband presented with developmental delay, seizures, diarrhea, acrocyanosis and petechiae. The EEG showed multifocal epilepsy. Brain MRI findings included injuries in deep basal ganglia and brain stem with diffusion restriction. The metabolic work-up demonstrated metabolic acidosis and high urine levels of ethylmalonic acid. The molecular analysis showed a novel mutation in ETHE1. The identification of this novel mutation in ETHE1 in a proband with a severe neurological involvement which includes multifocal epilepsy and restriction to the diffusion allows to expand the known phenotype of this lethal disorder.
550 - “Neuronal Ceroid Lipofuscinosis Like” Phenotype Masking RARS2 Mutations
Rayana Maia, Thereza Cavalcanti, Marina Estima Neiva Nunes, and Charles Lourenço
Hospital das Clínicas de Ribeirão Preto, Usp, Ribeirão Preto, SP, Brazil
551 - Pyruvate Dehydrogenase Deficiency: New Missense Mutation Due to Classic Phenotype
Alexandre Felício de Campos1, Rayana Maia1, Thereza Cavalcanti1, Linda de Meirleir2, Willy Lissens2, and Charles Lourenço1
1Hospital das Clínicas de Ribeirão Preto, Usp, Ribeirão Preto, SP, Brazil
2Center for Medical Genetics, University Hospital, Vrije Universiteit Brussel, Brussels, Belgium
P) Mitochondrial Disorders: Mtdna (552 to 561)
552 - Mitochondrial DNA Variation Among Emiratis
Fatma Al Jasmi1, Abdulkader Souid2, Ranjit Vijayan2, and Khalid Amiri2
1United Arab Emirates University, Abu Dhabi, United Arab Emirates
2UAEU, Al Ain, United Arab Emirates
This study investigated the mitogenome haplogroups and variants in 232 healthy Emirati citizens. Its main purposes were to study phylogenetic relationships in the tribal population, and describe novel mitochondrial DNA (mtDNA) variants in the region. Whole mtDNA sequences were used for these purposes. Major haplogroups with >10% frequency each were
553 - Different Clinical Phenotypes in Two Children With m.8362TG and m.8363GA MTTK Mutations
Ekaterina Nikolaeva1, Irina Leont’Eva1, and Yulia Itkis2
1Research and Clinical Institute of Pediatrics Named after Yuri Veltischev of the Pirogov University, Moscow, Russia
2Research Centre for Medical Genetics of the Russian Academy of Sciences, Moscow, Russia
554 - Reticular Dysgenesis and Mitochondriopathy Induced by Adenylate Kinase 2 Deficiency Identified in the Amish Population
Lina Ghaloul-Gonzalez, Al-Walid Mohsen, Anuradha Karunanidhi, Bianca Seminotti, Mark Vander Lugt, Allison Chirigos, M. Michael Barmada, Cate Walsh Vockley, Miguel Reyes-Múgica, and Jerry Vockley
University of Pittsburgh, Pittsburgh, PA, USA
555 - High-Coverage NGS Sequencing of Complete MT-DNA as Diagnostic Tool for Mitochondrial Disease
Uwe Ahting1, Bettina Lorenz-Depiereux2, Riccardo Berutti2, Bader Alhaddad1, Gertrud Eckstein2, Thomas Schwarzmayr2, Milena Radivojkov-Blagojevic2, Boris Rolinski3, Peter Lichtner2, Tim-Matthias Strom2, and Thomas Meitinger2
1Technische Universität München, Institute of Human Genetics, Munich, Germany
2Helmholtz Zentrum München, Institute of Human Genetics, Neuherberg, Germany
3Institute for Laboratory Pathology, Elblandklinikum, Meissen, Germany
We established a high-coverage next generation sequencing (NGS) procedure for mtDNA. The entire mtDNA was enriched by a single amplicon long-range PCR and analyzed by massive parallel sequencing. Sequence alignment to NC_012920 sequence with subsequent variant calling was performed. Technical sensitivity was 1% heteroplasmy for SNVs and allowed determination of heteroplasmy with high precision. For 297 samples, we achieved an average coverage of 6801 reads/sample. 27.6 variant per sample were detected. For diagnostic purposes, we set a heteroplasmy threshold of 10% (blood samples) and 20% (urine or muscle samples) for sequence variants being evaluated, to exclude likely insignificant variants. mtDNA deletions were detected by both, long-range PCR and the coverage analysis, the latter providing breakpoint information. In 2015 and 2016, we performed diagnostic high-coverage NGS of mtDNA for 189 index patients. Most of the patients were analyzed because of suspected mitochondrial disease (146/189, 17 among them MELAS), 22/189 for LHON and 21/189 for other indications. For patients with LHON and MELAS suspicion, the common mutations had been excluded in most cases by other methods before using high-coverage NGS. In one family, we could identify the most common MELAS mutation m.3243A>G after it had been missed by Sanger sequencing. Overall, we got 72 clinically relevant results. Half of them were deletions (36), many deletions associated with suspected CPEO (12/18) or other suspected mtDNA-deletion syndromes (3/10). In 16 cases, we found confirmed pathogenic point mutations, in 20 cases yet unreported variants of unknown significance with probability of relevance. Deletions were found in a higher proportion in adult samples than in pediatric samples as opposed to point mutations. In 29 cases with negative result of mtDNA high-coverage NGS we performed additional whole exome sequencing (WES). We found pathogenic relevant nuclear sequence variants in 14 cases (48.2%). GTPBP3 (3/14) and AARS2 (2/14) were detected in unexpected high number. 4/14 nuclear genes found in patients with suspected mitochondrial disease are not associated with mitochondrial function so far. In conclusion, high coverage mtDNA sequencing is an efficient tool for diagnosing mtDNA mutations in mitochondriopathies, especially in adult samples.
556 - Mitochondrial Dysfunction in Infantile Acute Liver Failure due to TRMU Gene Defect
Hernan Amartino1, Nora Atanacio2, Erika Selzer1, Marcelo Kauffman3, Mercedes Villanueva2, Victoria Aparo2, Alejandrina Real1, Tomas Iolster1, and Ivone Malla1
1Hospital Austral, Buenos Aires, Argentina
2Hospital Pedro de Elizalde, Buenos Aires, Argentina
3Instituto de Investigación En Medicina Traslacional Conicet, Buenos Aires, Argentina
557-Endothelial Dysfunction and the Effect of Arginine and Citrulline Supplementation in Children With Mitochondrial Diseases: Interim Results
Ayman El-Hattab, Nuha Al Zaabi, Jozef Hertecant, and Fatma Al Jasmi
Tawam Hospital, Al-Ain, United Arab Emirates
558-A Neurophysiologic Model of MELAS Disease, Using Inducible Pluripotent Stem Cell Derived Excitatory Neurons
Teun Klein Gunnewiek1, David Cassiman2, Eva Morava2, Nael Nadif Kasri1, and Tamas Kozicz1
1Radboud University Medical Centre, Nijmegen, the Netherlands
2University Hospital Leuven, Leuven, Belgium
Most individuals diagnosed with the common mitochondrial phenotype of MELAS carry the pathogenic variant 3243A>G in their mitochondrial DNA (mtDNA). Patients show a broad range of symptoms, involving mainly the skeletal muscle and the central nervous system. The mutation being present in the maternally inherited mtDNA, makes generating a knockdown/knockout animal model problematic. In order to increase our understanding on the neuropathobiology of mt.3243A>G we created human cortical neurons (iNeurons), derived from inducible pluripotent stem cells (IPSCs) and studied the impact of mt.3243A>G on mitochondrial- and neuronal (including synaptic) function. Patient-derived fibroblasts were reprogrammed to IPSCs, which were tested for heteroplasmy by sanger sequencing; three clones from the same patient, with different heteroplasmy levels (0%, 72%, and 83%) were expanded. These IPSC’s were differentiated into excitatory iNeurons by lentiviral rtta- and Neurogenin 2 (Ngn2) expression. Here we report on the characterization of the iNeurons both at the single-cell and neuronal network level. We describe whole-cell patch clamp recordings assessing spontaneous excitatory post-synaptic currents (sEPSC’s), combined with Mitotracker, MAP2- and Synapsin immunocytochemical staining. Additionally, we report on multi-electrode arrays (MEA’s) used to study the effects of the 3245A>G mutation on the network activity of the iNeurons. Our study illustrates the relevance of our patient-specific in vitro neurophysiologic model of mitochondrial involvement, which will enhance our understanding of the role of mitochondrial dysfunctions in neurological manifestations of MELAS disease.
559 - MELAS Syndrome: A Descriptive Study About 55 Patients From a French Department of Endocrinology, Diabetology, and Metabolism
Camille Loyer1, Claire-Marie Dhaenens2, Marie-Christine Vantyghem1, Anne Vambergue1, Dries Dobbelaere3, Karine Mention3, Aline Dernis3, and Claire Douillard1
1Hôpital Huriez Chru de Lille, Lille, France
2Cbp Chru de Lille, Lille, France
3Hôpital Jeanne de Flandre Chru de Lille, Lille, France
560-A Case Report of MELAS Syndrome With Early Diagnosis
Tamires Camargo, Nathalia Fernandes, Lilian Licurgo, Alessandra Braga, Viviane Santos, Hélio Rocha, Monica Moretzsohn, and Julia Albuquerque
Ippmg, Ufrj, Rio de Janeiro, RJ, Brazil
The goal is to demonstrate the importance of the early diagnosis of Melas syndrome. Information was obtained through interview with the patient and reviews of the literature and medical chart. ABSS, 4 years old, born full-term by C-section, normal blood spot test, started with 1 month of inconsolable crying, was prescribed infant formula, causing episodes of vomiting and dehydration. Started lactose-free amino acid formula, with no improvement. He presented hypoglycemia, high lactate dehydrogenase, normal abdominal ultrasound, MRI of the brain with signs of delay in the myelination and important lactate peak in the spectral analysis of the nuclei of the base on the right and of the ventricular system, electroencephalogram suggestive of West syndrome, metabolic acidosis, high anion gap, increased lactic and pyruvic acids, normal plasma, and urine amino acid chromatography. He had several hospitalizations due to worsening acidosis. Suspected of lactic acidemia and Leigh syndrome. Diagnosis made at 2 years by exome. He presented developmental delay, seizure, diffuse appendicular hypertonia with axial hypotonia. He evolved with malnutrition, then performed gastrostomy. He made use of carnitine, coenzyme Q10, complex B, and lamotrigine. Hypertonia and development improved, interacting better, smiling, gaining weight, decreased hospitalizations, reduced spasticity, and absence of seizures. MELAS syndrome is a rare mitochondrial disorder that begins in childhood, that affects especially the nervous system and muscles. Clinically, there are stroke-like episodes, encephalopathy, seizures, dementia, and mitochondrial myopathy evident by lactic acidosis or ragged-red fibers. A genetic study shows a mutation in the leucine transporter RNA gene, leading to the exchange of A by G at nucleotide 3243 of mtDNA, accounts for about 80% of cases. There is no specific approach for the treatment of individuals with MELAS syndrome, which is largely symptomatic. Comprehensive assessment, nutritional support and rehabilitation are necessary. Several supplements are being used based on limited clinical trials, like those used on this study, and they have been helpful in individual patients but further studies are needed to prove their efficacy. Although MELAS remains a largely untreatable condition, early diagnosis, prevention and management of medical complications may come to symptomatic relief and improvement of the quality of life, adding to the benefit of establishing a diagnosis.
561-Review, Clinical Presentation, Laboratory, and Genetical Findings on Seven Cases of Kearns Sayre Syndrome
Nora Atanacio, Consuelo Durand, Paula Ivarola, and Andrea Schenone
Chamoles Laboratory, Buenos Aires, Argentina
Q) Disorders of Purines, Pyrimidines, Nucleic Acids, and Porphyrias (562 to 568)
562 - Dihydropyrimidine Dehydrogenase Deficiency: Lack of Phenotype/Genotype Correlation and Ethical Perspectives of Termination of Affected Pregnancy
Sarar Mohamed, Esraa Elhassan, Amal Alhashem, and Aida Alaqeel
Prince Sultan Military Medical City, Riyadh, Saudi Arabia
563 - Effect of Intrastriatal Hypoxanthine Administration on Cellular Bioenergetic in Striatum of Young Adult Rats
Helena Biasibetti-Brendler, Carolina Gessinger Bertó, Felipe Schmitz, Paula Pierozan, Eduardo Peil Marques, and Angela Wyse
Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
Lesch-Nyhan disease (LND), an inborn error of purines metabolism, is characterized by oxypurine accumulation, mainly hypoxanthine. Purine represents an important role in cellular metabolism since it is substrate to the enzyme hypoxanthine-guanine phosphoribosyltransferase (HGPRT) in purine salvage pathway in the brain. The deficiency of HGPRT activity results in high concentrations of hypoxanthine, being that LND patients present 5 times the normal concentration of this purine in cerebrospinal fluid. Symptomatology of LND are cerebral palsy, cognitive and behavioral disturbances, motor dysfunction (spasticity, dystonia), self-mutilation behavior, as well as hyperuricemia. Although mechanisms of brain dysfunction in LND are poorly understood, it is believed that the accumulation of hypoxanthine contributes to neurological damage of this disease. Since this purine is closely related to ATP formation, in the present study we investigated the effect of this purine on cellular bioenergetic in striatum of young adult rats submitted to the intrastriatal hypoxanthine injection model. We evaluated Cytochrome c oxidase activity and immunoconent by Western Blotting, intracellular ATP levels, mitochondrial mass and mitochondrial membrane potential by MitoTracker. Sixty-day-old Wistar rats were divided into two groups: group 1 received hypoxanthine (10 μM) injection or saline (0.9%) injection. Thirty minutes after the administration, animals were decapitated and cerebral striatum were dissected. Results showed that hypoxanthine diminished cytochrome c oxidase activity, as well as its immunocontent (P <b.001 and P < v.01, respectively). Hypoxanthine administration also was able to decrease significantly ATP levels (P < .05). Further, hypoxanthine injection decreased the percentage of cells with mitochondrial membrane label (P < .01) and increased mitochondrial mass potential labeling (P < .05). These findings suggest that hyper-hypoxanthinemia, with levels similar to those found in LND patients, promotes energetic misbalance that might be related, at least in part, with the pathophysiology of Lesch-Nyhan disease. Supported by CNPq/Brazil.
564 - Phase 1, Randomized, Placebo Controlled Study of Givosiran, an Investigational RNA Interference (RNAi) Therapeutic, in Patients With Acute Intermittent Porphyria: Interim Study Results
Eliane Sardh1, Pauline Harper1, Manisha Balwani2, Penelope Stein3, David Rees3, Joseph Bloomer4, Dwight Bissell5, Robert Desnick2, Charles Parker6, John Phillips6, Herbert Bonkovsky7, Nabil Al-Tawil8, Craig Penz9, Amy Chan9, Chang-Heok Soh9, William Querbes9, Stephanie Rock9, Amy Simon9, and Karl Anderson10
1Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
2Mt. Sinai Icahn School of Medicine, New York, NY, USA
3King’s College Hosptial, London, United Kingdom
4Universtiy of Alabama, Birmingham, AL, USA
5University of California, San Francisco, CA, USA
6University of Utah, Salt Lake City, UT, USA
7Wake Forest University, Winston-Salem, NC, USA
8Karolinksa University Hospital, Stockholm, Sweden
9Alnylam Pharmaceuticals, Cambridge, MA, USA
10University of Texas Medical Branch, Galveston, TX, USA
Acute hepatic porphyrias (AHP) are a family of rare, serious and life-threatening metabolic diseases predominantly caused by a genetic mutation in one of the enzymes required for heme synthesis in the liver. Acute intermittent porphyria (AIP) is the most common subtype of AHP. AIP is characterized by disabling neurovisceral attacks and chronic disease symptoms, that are secondary to the upregulation of the first and rate-limiting step in heme synthesis, ALA synthase 1 (ALAS1), and the accumulation of the neurotoxic heme intermediates aminolevulinic acid (ALA) and porphobilinogen (PBG). With prolonged and severe attacks, paralysis, respiratory failure and death can occur. Givosiran (ALN-AS1) is an investigational RNAi therapeutic targeting ALAS1 mRNA in the liver in order to decrease the accumulation of the neurotoxic heme intermediates ALA/PBG, and thereby potentially reduce subsequent porphyria disease activity. We are conducting a phase 1 randomized, placebo-controlled, study in 3 parts to evaluate the safety, tolerability, pharmacokinetics, and pharmacodynamics of subcutaneously (SC) administered givosiran in patients with AIP (Part A, single ascending dose; Part B, multiple ascending dose; and Part C, multiple dose). In addition, Part C examines the impact of givosiran treatment on porphyria disease activity (ClinicalTrials.gov Identifier: NCT02452372). Interim data from Parts A, B, and C of the study suggest givosiran was generally well tolerated with no serious adverse events or clinically significant laboratory abnormalities related to study drug, and no discontinuations due to drug-related adverse events. Givosiran treatment also led to significant dose-dependent and sustained reductions in ALAS1, ALA and PBG with single and multiple doses. In Cohort 1 of Part C, significant clinical activity was demonstrated in givosiran treated patients as evidenced by a 74% decrease in annualized attack rate, a 75% decrease in annualized hemin usage, and a mean maximum attack-free interval in the treatment period that is approximately 10.5 times that observed during the run-in period (up to 6 months). Interim progress and data from subsequent cohorts of Part C will be presented. ENCORE presentation.
565-EXPLORE: A Prospective, Multinational Natural History Study of Patients With Acute Hepatic Porphyria (AHP) With Recurrent Attacks
Laurent Gouya1, Joseph Bloomer2, Manisha Balwani3, Dwight Bissell4, David Rees5, Ulrich Stolzel6, Robert Desnick3, Charles Parker7, Penelope Stein5, Elizabeth Minder8, Jerzy Windyga9, Pavel Martasek10, Paolo Ventura11, Aneta Ivanova12, Amy Chan13, Chang-Heok Soh13, William Querbes13, Craig Penz13, Amy Simon13, and Karl Anderson14
1Centre Francais Des Porphyries, Paris, France
2University of Alabama, Birmingham, AL, USA
3Mt. Sinai Icahn School of Medicine, New York, NY, USA
4University of California, San Francisco, CA, USA
5King’s College Hospital, London, United Kingdom
6Klinikum Chemnitz, Chemnitz, Germany
7University of Utah, Salt Lake City, UT, USA
8Stadtspital Triemli, Zentrallabor, Zurich, Switzerland
9Instytut Hematologii I Transfuzjologii, Warsaw, Poland
10Univerzity Karlovy V Praze, Prague, Czech Republic
11Università Degli Studi Di Modena e Reggio Emilia, Modena, Italy
12St. Ivan Rilski University Hospital, Sofia, Bulgaria
13Alnylam Pharmaceuticals, Cambridge, MA, USA
14University of Texas Medical Branch, Galveston, TX, USA
The acute hepatic porphyrias (AHPs) are characterized by chronic disabling disease symptoms and potentially life-threatening neurovisceral attacks, often requiring urgent medical care and/or hospitalization. Three types of AHPs are acute intermittent porphyria (AIP), variegate porphyria (VP), and hereditary coproporphyria (HCP), which are rare diseases caused by a genetic mutation in one of the enzymes required for heme biosynthesis, resulting in accumulation of neurotoxic heme intermediates. EXPLORE is a prospective, international, observational study characterizing the natural history and clinical management of patients with AHP with recurrent attacks (>3 attacks/year) or who receive prophylaxis to prevent attacks. Patient medical history, physical examination and porphyrin precursors, along with questionnaires on porphyria activity, quality of life and health-care utilization were collected. A total of 112 patients with AHP enrolled from 13 countries, and have been followed for 6 to 12 months. Mean patient age is 39 years, with 89% female, and 93% with AIP, 4% VP, and 3% HCP. Patients reported 9.5 attacks in the 12 months prior to the study, with pain being the most common symptom in 99% of attacks. Chronic symptoms were also reported by 64% of patients in between attacks, with pain being the most frequent symptom. While on study, the annualized attack rate in patients was 4.4 attacks/person, of which 76% required treatment at a healthcare facility or with intravenous hemin. Patients reported diminished quality of life (EQ-5D-5 L), with the greatest impact seen in the domains of pain/discomfort, usual activities and anxiety/depression. EXPLORE is the first international natural history study in patients with AHP and recurrent attacks and demonstrates that patients suffer from both acute attacks, and chronic symptoms (most commonly pain) in between attacks that together result in a diminished quality of life. Updated 12-month data will be presented from the study. ENCORE presentation.
566 - Analysis of the HPRT1 Gene Mutations in 6 Russian Families With Lesch-Nyhan Syndrome
Maria Yablonskaya1, Svetlana Papij1, Oksana Komarova1, Malvina Harabadze1, Yulia Davydova1, Maria Prytkina1, Natalia Milovanova2, and Ekaterina Nikolaeva1
1Research and Clinical Institute of Pediatrics Named after Yuri Veltischev of the Pirogov University, Moscow, Russia
2Research Centre for Medical Genetics of the Russian Academy of Sciences, Moscow, Russia
Lesch-Nyhan syndrome is an X-linked inborn error of purine metabolism caused by mutations in the HPRT1 gene encoding the purine recycling enzyme hypoxanthine phosphoribosyltransferase (OMIM 308000). Urate hyperproduction and nephropathy in this disease can be combined with neurologic impairment, which leads to three overlapping clinical phenotypes: (1) the classical form of the Lesch-Nyhan disease characterized by cognitive impairment, dystonia, spasticity, self-injurious behavior, and urate nephropathy; (2) intermediate phenotype with hyperuricemia and variable neurological manifestations with no self-injurious behavior; and (3) hyperuricemia alone. The purpose of the study was to identify pathogenic mutations in the HPRT1 gene in a cohort of patients with the Lesch-Nyhan syndrome in the Russian Federation. During the period 2012 to 2017, seven boys aged 16 months up to 14 years with different clinical variants of Lesch-Nyhan disease from six unrelated families have been identified and genetic analysis of the HPRT1 gene has been performed by direct automatic sequencing of the entire coding region of the gene, including exon-intron boundaries. All of the patients examined in this research had hemizygous variants in the HPRT1 gene; three of them have not been previously described. The deletion of three nucleotides within the reading frame c.24-26delCTG (CD070472), missense mutation c.610C> G (CM880047) and the new missense mutation c.464C> T (p.155Pro>Leu) were detected in three unrelated patients with the classic phenotype of the Lesch-Nyhan disease. In three probands with neurological dysfunction and hyperuricemia with no self-mutilating behavior we have detected two HPRT1 gene variants: the new missense-mutation c.599G>A (p.200Arg>Lys) in one patient and c.635G> A (CM002634) in two siblings. In the 14-year-old boy who had hyperuricemia with no neurological dysfunction we detected a novel single-base substitution: c.359T> G (p.122Leu>Arg). The phenotypic manifestations of Lesch-Nyhan syndrome variants in Russian patients with previously described mutations did not differ from those of patients described in the world research. The exception was the child with mutation c.610C> G (CM880047), who had an extremely early formation of chronic renal failure at the age of 16 months. Three mutations in the HPRT1 gene that have been probably unknown before were identified. According to the PolyPhen2 algorithm, these amino acid changes are probably pathogenic.
567 - Subacute Partially Reversible Leukoencephalopathy Expands the Phenotype of Aicardi-Goutières Syndrome
Isabella Barcelos1, Andre Pessoa2, Larissa Costa1, Fernanda Monti1, Katiane1, Bruno Della Ripa1, Fernando Freua1, Lais Pires3, Lia T Krüger4, Flávia Piazzon1, Fabíola Monteiro5, Leandro Lucato1, Clarissa Bueno1, and Fernando Kok1
1University of São Paulo School of Medicine, São Paulo, SP, Brazil
2Albert Sabin Child Hospital, University of State of Ceará, Fortaleza, CE, Brazil
3None, Rio de Janeiro, RJ, Brazil
4Paulo Niemeyer's Brain State Institute, Rio de Janeiro, RJ, Brazil
5Mendelics Genomic Analysis, São Paulo, SP, Brazil
Aicardi-Goutières syndrome (AGS) is a genetic encephalopathic and immunologic disorder that results from mutations in TREX1, RNASEH2A, RNASEH2B, RNASEH2C, SAMHD1, ADAR1, and IFIH1 genes. It usually presents in infancy with basal ganglia calcification (mimicking congenital infection), white matter abnormalities, chronic CSF lymphocytosis, and increased serum levels of alpha-interferon. Despite the delineation of clinical, radiological, and biochemical criteria for the diagnosis of AGS, the range of phenotypic presentations associated with mutations in AGS related genes might be wider than previously claimed. We report five unrelated patients (four males) with subacute loss of developmental milestones, pyramidal signs and regression of communication abilities, with onset at ages ranging from 14 to 20 months. Recurrence of demyelination occurred in one patient at age of 5. Currently, age of patients varies from four to nineteen years. Pregnancy, labor and initial development was unremarkable for all patients and parental consanguinity was present in one individual. One patient received a yellow fever shot 2 weeks before disease onset. CSF at active phase of disease was normal in four patients (one had mild lymphocytosis in both events) and, on brain CT-scan, a single patient had a very subtle basal ganglia calcification. At onset, brain MRI showed in all patients, asymmetric demyelination of white matter with centrum semiovale involvement without contrast enhancement. All them were diagnosed and/or treated as acute demyelinating encephalomyelitis (ADEM) during the acute phase, despite the atypical presentation. At one year of follow-up, brain imaging was markedly improved but patients remained with residual spasticity and dysarthria. Diagnosis was established by whole exome sequencing or leukodystrophy genes panel, and three patients were found to carry biallelic pathogenic variants on RNASEH2B (2 homozygous p.Ala177Thr and 1 compound heterozygous p.Ala177Thr/p.Gln58*) and two in RNASEH2A (homozygous p.Ala249Val). This report expands the phenotype of AGS to include subacute developmental regression with partial recovery clinical and radiological reversible leukoencephalopathy. These clinical features might be misdiagnosed as ADEM.
568-Patients With Hypoxantine-Guanin Phosphoribosyltransferase Deficiency
Havva Yazici1, Ebru Canda1, Sema Kalkan Uçar1, Huseyin Onay2, Ferda Ozkinay3, and Mahmut Coker1
1Division of Pediatric Metabolism and Nutrition, Ege University Faculty of Medicine, Izmir, Turkey
2Division of Medical Genetics, Ege University Faculty of Medicine, Izmir, Turkey
3Division of Medical Genetics and Pediatric Genetics, Ege University Faculty of Medicine, Izmir, Turkey
Hypoxantine-guanin phosphoribosyltransferase (HGPRT) takes part in purine metabolism and it is recessively inherited based on X with HPRT1 gene. Clinical spectrum is extensive in enzyme deficiency and extends from hyperuricemia related to HGPRT, neurological dysfunction and classic Lesch-Nyhan disease. It was aimed to present two patients displaying two extreme clinical tables. A four-month old male infant had no active complaint and he was evaluated with increased serum uric acid level. His development and growth were normal. His serum uric acid increased as; 14.4 mg/dl (N:2–5.5 mg/dl). Hemizygote p.Y72C mutation was determined in HPRT1 gene. There was a phenotype- genotype correlation and he had no additional finding other than hyperuricemia concerning HGprt. A three-year old male patient was referred with tyrosine hydroxylase pre-diagnosis. Delay in the development steps, biting himself, repetitive urinary tract infections and uneasiness were present in the history. In the physical examination, there were conditions including growth and developmental delay, biting marks on hands and lips, dystonia, and uneasiness. Serum uric acid increased 11.8 mg/dl (N:2-5.5), medullary nephrocalcinosis was identified in the urinary ultrasonography. In the examination performed in epicenter, Homovanilic acid (HVA) was low (52 nmol/L) in brain cerebrospinal fluid (according to age N: 211-871), 5- hydroxyindol acetic acid (5–HİAA) was normal 310 nmol/L (N:105-299) and HVA/5-HIAA level was low 0.16 (N:1.5-3.5). However self-mutilation, repetitive urinary tract infection, hyperuricemia led to Lesch Nyhan disease pre-diagnosis. Hemizygote p.R51P mutation was established in the HPRT1 gene. In the presence of unexplained hyperuricemia and/or unexplained neurological findings, growth deficiency, behavior issues, movement disorder and self-mutilation evidence; HGPRT deficiency should take part in the definitive diagnosis. It should be kept in mind that clinic spectrum is extensive.
R) Peroxisomal, Sterol, Bile Acid, Lipid and Lipoprotein Disorders (569 to 584)
569 - Glutathione and Sulfhydryl Levels in X-Linked Adrenoleukodystrophy Patients: The Effect of N-Acetyl-L-Cysteine
Desirèe Marchetti, Bruna Donida, Tatiane Hauschild, Aline Kayser, Camila Delgado, Marion Deon, Carlos Eduardo Diaz Jacques, Laura Jardim, and Carmen Regla Vargas
Ufrgs, Porto Alegre, RS, Brazil
X-linked adrenoleukodystrophy (X-ALD) is an inborn error of peroxisome metabolism. Hexacosanoic acid (C26:0) and tetracosanoic acid (C24:0) are saturated fatty acids that accumulate in tissues and body fluids. The exact mechanisms underlying brain damage in X-ALD are poorly elucidated, but some researchers have proposed that oxidative stress represents a hallmark in the pathogenesis of X-ALD. The antioxidant capacity of N-acetyl-L-cysteine (NAC) has been proposed based on data from in vitro studies, in which this compound has been shown to reduce oxidant induced cell damage, acting as a cysteine prodrug and a glutathione (GSH) precursor. GSH plays a wide variety of physiological roles and its antioxidant effects depend on the presence of the free sulfhydryl group as a ready source of reducing equivalents to quench radical species. NAC can also reduce disulfide bonds in proteins, scavenge free radicals and bind metals to form complexes. Considering that NAC has been proposed as a GSH precursor, the aim of this study was to analyze the in vitro effect of NAC on GSH and sulfhydryl levels in X-ALD patients. A total of eight X-ALD patients were included in this study (four heterozygotes women, one Addison only and three patients with cerebral form). Venous blood was collected under sterile conditions in heparinized vials, and blood cells were incubated with NAC (2.5 and 5 mM) for 6 hours. Then, the blood was centrifuged, GSH content was analyzed in erythrocytes and sulfhydryl levels were performed in plasma. All subjects or parents gave written informed consent. A significant reduction of GSH and sulfhydryl content was observed in X-ALD patients compared to the control group. Furthermore, 5 mM of NAC, in vitro, led to an increase in GSH content and sulfhydryl groups in these patients. The present results confirm former reports showing the role of oxidative stress on X-ALD and demonstrate the in vitro protective effect of NAC on GSH and sulfhydryl content in this disease. Therefore, this study underscores the pertinence of using antioxidants as an adjuvant therapy for X-ALD to improve oxidative imbalance in X-ALD patients.
570 - Expanding Our Understanding of Cerebral Adrenoleukodystrophy and Interim Phase 2/3 Results of an Autologous Hematopoietic Stem Cell Gene Therapy
Hernan Amartino1, Florian Eichler2, Christine Duncan2, Patricia Musolino2, Paul Orchard3, Satiro de Oliveira4, Adrian Thrasher5, Troy Lund3, Weston Miller3, Gerald Raymond3, Asif Paker6, Maria Escolar7, Alain Fischer8, Gerard Michel9, Vinod Prasad10, Nicholas Smith11, Joseph Biedenkapp6, Mohammed Asmal6, Patrick Aubourg8, and David Williams12
1Hospital Universitario Austral, Buenos Aires, Argentina
2Massachusetts General Hospital, Boston, MA, USA
3University of Minnesota, Minneapolis, MN, USA
4University of California Los Angeles, Los Angeles, CA, USA
5Institute of Child Health, London, United Kingdom
6Bluebird Bio, Cambridge, MA, USA
7Children’s Hospital Pittsburgh, Pittsburgh, PA, USA
8Inserm, Paris, France
9Hôpital Pour Enfants La Timone, Marseille, France
10Duke University School of Medicine, Durham, NC, USA
11Women’s and Children’s Hospital, Metabolic Clinic, Adelaide, Australia
12Boston Children’s Hospital, Boston, MA, USA
571-Preliminary Results of Our Laboratory for Bile Acid Metabolism Disorders
Gursel Biberoglu, Betul Grnc Derin, Asli İnci, Ilyas Okur, Fatih Süheyl Ezgü, and Leyla Tümer
Department of Pediatric Metabolism and Nutrition, Gazi University Medical Faculty, Ankara, Turkey
The measurement of plasma sterols is an important biomarker for diagnostic purposes in cholesterol and bile acid metabolism disorders. In this study, we aimed to analyze plasma sterol levels by GC-MS in our laboratory and diagnose bile acid and cholesterol metabolism disorders. This method is based on the principle of alkaline hydrolysis of sterol esters, extraction of free sterols with organic solvent and derivatization with BSTFA 1%TMCS + pyridine. After derivatization, we analyze the sterols on the GC-MS with SIM mode. Quantitative analysis of cholesterol, 7-dehydrocholesterol, cholestanol levels, as well as several sterols such as lathosterol, campesterol, and sitosterol are possible with this method. The measurement of unconjugated bile acids and alcohols with GC-MS is the most valid method. Good separation by gas chromatography and increased specificity and sensitivity by “selected ion monitoring” (SIM) on the mass spectrometer provides the advantage of this method. The reproducibility (CV) of the method for cholestanol and 7-dehydrocholesterol was 8.94% and 6.92%, respectively, and recovery was 95.63% and 99.3%. We analyzed plasma sterols of 95 healthy person for the determination of reference range in our laboratory. Reference range of cholestanol levels were determined as 3-16.9 µmol/L and this value was found compatible with the literature. External quality control of this analysis was provided by ERNDIM quality control program. Plasma sterol analysis was performed on 10 suspicious patients with bile acid metabolism disorders and we found that 2 patients had high cholestanol levels (105.17 and 114.18 µmol/L, reference range 3-16.9 µmol/L). Molecular genetic analysis was planned for these patients. The measurement of plasma sterols is an important parameter in the diagnosis of bile acid metabolism disorders and following treatment.
572-Next Generation Exome Sequencing in the Molecular Diagnosis of Primary Hypobetalipoproteinemias: Report of Four Turkish Cases
Berna Seker Yilmaz1, Patrizia Tarugi2, Deniz Kor3, Enza Di Leo2, Derya Bulut4, Claudio Rabacchi2, Sebile Kilavuz4, and Neslihan Mungan4
1Mersin City Hospital, Mersin, Turkey
2Universita Di Modena e Reggio Emilia, Modena, Italy
3Adana Numune Hospital, Adana, Turkey
4Cukurova University, Adana, Turkey
Primary hypobetalipoproteinemias (HBLs) include three genetic disorders characterized by reduced plasma levels of total cholesterol, low density lipoprotein cholesterol (LDL-C), apolipoprotein B (apoB) and associated with a wide spectrum of clinical findings. Abetalipoproteinemia (ABL) and Chylomicron Retention Disease (CMRD) are two autosomal recessively inherited, rare pathologies of lipid metabolism, defined with a severe picture related to intestinal lipid malabsorption. However, familial Hypobetalipoproteinemia (FHBL) is a relatively frequent, autosomal dominant inherited metabolic disorder, often coexist with fatty liver and fat malabsorption (in some homozygotes). We investigated four Turkish patients who were referred to our clinic for etiological evaluation of severe intestinal lipid malabsorption, hepatic steatosis and growth retardation, together with very low levels of total cholesterol, LDL-C and apoB, and suggesting the diagnosis of ABL or CMRD. To define the molecular defect, we performed a parallel sequencing (targeted next generation sequencing) of 16 primary HBLs related genes, including the main candidate genes (APOB, MTTP, SAR1B and ANGPTL3). Genomic DNA sequencing of the candidate genes showed that three patients, all born from consanguineous parents, were homozygous for pathogenic mutations in MTTP gene: i) a single nucleotide substitution in intron 7 (c.909+1G>A) which involves the donor splice site of this intron, causing a splicing defect with the formation of an abnormal mRNA predicted to encode a truncated protein devoid of function; this mutation has not been reported previously and found in two siblings; ii) a 17 nucleotide deletion in exon 1 (c.57del17) predicted to cause a frameshift with the formation of a premature stop codon at position 26 resulting in a truncated MTP protein of 25 amino acids, devoid of function. This mutation has been reported previously in an ABL patient. In the fourth patient, no definite pathogenic variants were found. This patient was found to be heterozygous for a rare missense variant in ANGPTL4 (p.Phe248Leu) which was found to be damaging in “silico”. However, its clinical significance is uncertain. In conclusion, targeted next generation sequencing allows the rapid molecular diagnosis of rare genetic heterogeneous disorders like HBLs.
573 - Molecular Analysis of Hyperoxaluria Type 1 in Two Southwestern Colombian Patients Reveals the Same Mutation on the Alanine-Glyoxylate Aminotransferase Gene
Lina Johanna Moreno Giraldo1, Jose Maria Satizabal Soto2, Adalberto Sanchez2, Patricia Landazuri3, Beatriz Restrepo Cortés3, and Nelsy Loango Chamorro3
1Universidad Del Valle, Universidad Santiago de Cali, Cali, Colombia
2Universidad Del Valle , Cali, Colombia
3Universidad Del Quindio, Armenia, Colombia
Primary hyperoxaluria (PH) type 1 is a rare autosomal recessive disorder characterized by an accumulation of calcium oxalate in various bodily tissues, especially the kidney, resulting in renal failure. Type I PH (MIM 259900) is caused by absent, deficient, or mistargeted activity of the liver-specific peroxisomal enzyme alanine-glyoxylate aminotransferase (AGT; MIM 604285). This enzyme catalyzes the transamination of L-alanine and glyoxalate to pyruvate and glycine. The enzyme defect has been attributed to mutation in the AGXT gene located on chromosome 2. The overproduction of oxalate results in the accumulation of nonsoluble calcium oxalate in various body tissues, with pathologic sequelae. The prevalence of PH1 is approximately 1-3 cases per million on world population. At least 1% of the End Stage Renal Disease seen in the pediatric population is attributable to PH1 in European and Japanese studies. Two infant female patients non-consanguineous from Colombian Southwestern region with clinical history of global neuro-developmental delay, convulsions, myoclonus, hypotonia, optic atrophy, Raynaud phenomenon, Hematuria per episode of renal stone resolved without Renal failure, pathologic fractures, and osteosclerosis were reported. Exome sequencing was performed on the iIIumina platform finding the same single nucleotide variant in both patients (C> T) on gene AGXT, registered as rs34116584, with heterozygous inheritance mode, an missense effect, and previously associated with pathogenicity. Hyperoxaluria continues to be a challenging disease and appropriate treatment requires a high index of suspicion and timely diagnosis. Prompt clinical recognition and distinction between these disorders is essential not only for timely intervention but also prognosis impacts in patients with hyperoxaluria.
574 - A Metabolomic Map of Mild Peroxisome Biogenesis Disorders Reveals Sphingomyelins as Novel Disease Biomarkers
Sarah Elsea1, Leroy Hubert1, Taraka Donti1, Meredith Ventura1, Marcus Miller1, Nancy Braverman2, Kelly Gowran3, Mousumi Bose3, Ann Moser4, Richard Jones4, William Rizzo5, V. Reid Sutton6, Qin Sun1, Adam Kennedy7, and Michael Wangler1
1Baylor College of Medicine, Houston, TX, USA
2Research Institute of The Mcgill University Health Center, Montreal, Canada
3Montclair State University, Montclair, NJ, USA
4Kennedy Krieger Institute, Baltimore, MD, USA
5University of Nebraska Medical Center, Omaha, NB, USA
6Baylor College of Medicine, Houston, TX, USA
7Metabolon, Raleigh, NC, USA
Peroxisomal biogenesis disorders in the Zellweger spectrum (PBD-ZSD) are pediatric metabolic and multisystemic diseases ranging from severe forms with seizures, neuronal migration defects, hypotonia, and death within 1 year of life, to milder forms with developmental delay, retinopathy, and hearing loss. Patients with PBD-ZSD exhibit impaired peroxisomal biochemical functions and have abnormal levels of peroxisomal metabolites. We ascertained a cohort of 19 individuals with clinically and molecularly characterized mild to moderate PBD-ZSD who presented with hearing loss, developmental delay, and varied observations of microcephaly, retinopathy, and movement disorders. Analysis of plasma samples included quantitative peroxisomal biochemical diagnostics in parallel with untargeted small molecule metabolomic profiling with detection of >650 named molecules. The cohort represented a mild subset of PBD-ZSD with mild peroxisomal biochemical alterations on targeted analysis. Untargeted metabolomic profiling showed anticipated alterations in pipecolic acid, long chain fatty acids, long chain lysophosphatidylcholines, several bile acids, and plasmalogens. In addition, multiple sphingomyelin species were reduced in every patient sample. These perturbations in the plasma metabolomic profiles are unique, specific, and not previously seen in >1000 other samples analyzed as normal controls or for other indications. Reduced sphingomyelin was one of the strongest effects observed in these samples and detected only by untargeted metabolomic profiling. Interestingly, all of the metabolic abnormalities in PBD-ZSD were more pronounced in younger subjects, suggesting studies earlier in life reveal larger biochemical changes. As the clinical presentation of mild PBD-ZSD broadens and as clinical sequencing identifies novel genetic variants, the need for assessment of peroxisomal function increases. The use of untargeted metabolomics in the analysis of PBD can provide insight into pathogenesis, identify novel biomarkers of disease, and may provide novel indicators for therapeutic monitoring. Untargeted metabolomic screening identified several specific biomarkers that taken together allow for effective detection of these mild cases of PBD-ZSD, ending the diagnostic odysseys for many of these patients.
575 - Universal Population Screening of Cholesterol in Slovakia—Experiences of East Slovakia Center
Jana Saligova1, Ludmila Potocnakova1, Ingrid Schusterova1, Jan Saliga2, Pavol Simurka3, Stefan Rosipal4, and Anna Hlavata5
1Department of Pediatrics, Children’s Faculty Hospital, Kosice, Kosice, Slovakia
2Tu Kosice, Kosice, Slovakia
3Faculty Hospital, Ad University, Trencin, Slovakia
4Lipmet, Poprad, Slovakia
5Comenius University Children’s Faculty Hospital, Bratislava, Slovakia
576-Alpha-Methylacyl-CoA Racemase deficiency: Atypical Presentation in Four Patients
Gülden Gökçay1, Seda Güneş1, Gonca Bektaş2, Mehmet Cihan Cihan Balci3, Behiye Alyanak4, Mübeccel Demirkol1, and Yeşim Parman5
1Istanbul University Istanbul Medical Faculty Division of Pediatric Nutrition and Metabolism, Istanbul, Turkey
2Istanbul University Istanbul Medical Faculty Division of Pediatric Neurology, Istanbul, Turkey
3Tokat Governmental Hospital, Tokat, Turkey
4Istanbul University Istanbul Medical Faculty Pediatric Psychiatry, Istanbul, Turkey
5Istanbul University Istanbul Medical Faculty Department of Neurology, Istanbul, Turkey
577 - Hypertriglyceridemia Secondary to Congenital Generalized Lipodystrophy in a Four Months Old Baby
Hui Joannie1, Sc Chong1, Lk Law2, P Yau3, Yp Yuen2
1Department of Paediatrics, Prince of Wales Hospital, the Chinese University of Hong Kong
2Department of Chemical Pathology, Prince of Wales Hospital, the Chinese University of Hong Kong
3Department of Dietetics, Prince of Wales Hospital, the Chinese University of Hong Kong
578 - Investigation of LDLR Gene Mutations in Turkish Patients With Familial Hypercholesterolemia
Ilyas Okur1, Asli Inci1, Asburce Bike Olgac2, Bahattin Ciftci1, Burcu Topcu1, Leyla Tümer1, and Fatih Süheyl Ezgü1
1Gazi University School of Medicine, Ankara, Turkey
2Gazi University School of Medicine, Pediatric Metabolism and Nutrition, Ankara, Turkey
Familial hypercholesterolemia (FH) is characterized by severely elevated LDL (low-density lipoprotein) cholesterol levels that lead to an increased risk for cardiovascular disease. An estimated 70% to 95% of FH results from a heterozygous pathogenic variant in one of three genes (APOB, LDLR, and PCSK9). Many people have mutations in the LDLR (low-density lipoprotein receptor) gene that encodes the LDL receptor protein, which normally removes LDL from the circulation. The aim of our study was to examine the genetic background of Turkish patients suspected of FH.
579 - Case Report of a LAL-D Infant Presentation: Going Beyond Known Boundaries
Jose Simon Camelo Jr, Jacqueline Monteiro, Regina Sawamura, Marcela Bicesto, Charles Lourenço, Ana Beatriz Gonçalves
Ribeirão Preto Medical School, University Of São Paulo, Ribeirão Preto, SP, Brazil
The early onset lysosomal acid lipase deficiency (LAL-D) phenotype is usually fatal in the first year of life. Recently, enzyme replacement therapy (ERT) for LAL-D became available. The main goal of this report is to present a successful case of an LAL-D infant presentation on ERT since she was born. S.R., female, consanguineous parents, brother not treated deceased with LAL-D, 98 days old. She was born in good conditions: Wt = 3210 g, Ht = 48 cm. A new homozygous mutation was detected prenatally: exon 4 - gene LIPA, c266>c (p.leu89pro). In silico analysis suggested a pathogenic mutation. Hospital discharge on second day of life and ERT with Sebelipase Alfa, on fourth day of life: 3 mg/kg/every week (EW). Increased dose of ERT to 5 mg/kg/EW (3-6 mg/kg/EW during 3 months) due to persistence of the symptoms. Feeding with a polymeric formula with no lipids, designed to fatty acid β-oxidation defects. Baby was not growing, presenting severe undernutrition and intestinal malabsorption (12%) and diagnosed with heterologous protein allergy. Exchanged to amino acids formula. Abdominal ultrasounds showed hepatomegaly and adrenal calcifications. 3 months old: admitted at ER with severe abdominal distension, pain, sepsis and went to laparotomy. Surgery findings: fat deposition on lymph nodes and bowel distension. Post-op: satisfactory evolution, but initially with total parenteral nutrition (TPN). Presented hyperthermia during ERT: pre-medication (antihistaminic and antipyretic drugs) before ERT. 7 months old: increased frequency of ERT to 5mg/kg/dose twice a week. Using central venous access for TPN, had 3 septic episodes. Afterward, she improved intestinal absorption, allowing the advance of enteral nutrition (76% absorption). Last nutritional assessment (1 y 19 d): Wt = 6.265 g; Ht = 61.5 cm; IMC = 16.45kg/m2. Laboratories are getting better from the beginning (AST, ALT, gamma-GT; total cholesterol and fractions; triglycerides and hemoglobin). Diet: used modulated amino acids formula until development of tolerance of intact protein. Now she is receiving a skimmed modulated formula: 185 kcal/kg/d, 4,9 g ptn/kg/d, 10% lipids; complimentary food; multivitamins. Diet goals: catch-up growth and neurodevelopment. To the best of our knowledge, she is one of the 6 children alive from all over the world with LAL-D on ERT. The very early diagnosis and treatment (ERT) combined with an appropriate management of the serious complications allowed a survival in good conditions.
580 - Diagnosis of Peroxisomal Storage Disorders by Very Long Chain Fatty Acids analysis: Experience at Quest Diagnostics Nichols Institute Biochemical Genetics Laboratory
Rajesh Sharma, Denise Salazar, Ruben Bonilla-Guerrero, Abdul Reza Davoodi-Semiromi, and Felicitas Lacbawan
Quest Diagnostics Nichols Institute, San Juan Capistrano, USA
581 - PEX16 Mutations Presenting as a Mild Peroxisome Biogenesis Disorder
Osama Aldirbashi, Fatma Al Jasmi, and Nuha Al Zaabi
College of Medicine and Health Science, UAE University, Alain, United Arab Emirates
582 - Serum of VLCFA Levels in the Diagnosis of X-ALD/AMN Heterozygotes
Teresa J Stradomska1, Jolanta Kubalska2, Anna Tylki-Szymanska1
1Child Mem Health Inst, Warsaw, Poland
2Institute of Psychiatry and Neurology, Warsaw, Poland
X-linked adrenoleukodystrophy, X-ALD (MIM 300100), is a neurodegenerative peroxisomal disorder caused by mutations in ABCD1. X-ALD is clinically heterogeneous, and can present at a variety of ages. Biochemically, it is characterized by the accumulation of very long-chain fatty acids (VLCFAs), particularly lignoceric (C24:0) and cerotic (C26:0) acids in blood and tissues.
583 - A Case Report of a 6 Years Old Turkish Patient With Neonatal Adrenoleukodystrophy and a Mutation in the PEX26 Gene
Sebile Kilavuz1, Fatma Derya Bulut1, Berna Seker Yilmaz1, Deniz Kor1, Bilgin Yüksel2, Ozlem Herguner3, Gülay Ceylaner4, and Neslihan Mungan1
1Department of Pediatric Metabolism and Nutrition, Faculty of Medicine, Çukurova University, Adana, Turkey
2Department of Pediatric Endocrinology, Faculty of Medicine, Çukurova University, Adana, Turkey
3Department of Pediatric Neurology, Faculty of Medicine, Çukurova University, Adana, Turkey
4Intergen Genetic Laboratory, Ankara, Turkey
584 - NV1205 for the Treatment for X-Linked Adrenoleukodystrophy (X-ALD)
Giovanni Ferrara1, Masoud Mokhtarani1, and Thomas Scanlan2
1Neurovia, Inc, San Francisco, CA, USA
2Department of Physiology and Pharmacology, Oregon Health & Science University, Portland, OR, USA
X-ALD is a genetic disease due to mutation of the ABCD1 gene on the X-chromosome with a worldwide incidence of 1:17,000. ABCD1 encodes a peroxisomal membrane protein that facilitates transport and degradation of very long chain fatty acids (VLCFA) in the peroxisome. ABCD1 mutations result in an inability to degrade VLCFA. VLCFA accumulates in all tissues, and accumulation in the neuronal white matter and adrenal cortex leads to Addison’s disease and varying degrees of neurological symptoms. Approximately 40% of affected young males develop a cerebral form of the disease, or childhood cerebral ALD (CCALD), characterized by cerebral inflammation, rapidly developing white matter lesions, severe neurological symptoms, vegetative state, and death in a few years. Adrenomyeloneuropathy (AMN) is the adult form of the disease manifested by spinal cord axonopathy leading to slowly progressive neurological symptoms such as paraparesis, gate disturbances, and fecal and urinary incontinence. The only available treatment for CCALD is hematopoietic stem cell transplant that must be performed early in the course of the disease to be effective. There is no therapy available for AMN. ABCD2, a gene encoding a homologous peroxisomal transporter to ABCD1, is an attractive therapeutic target with the possibility of correcting the underlying biochemical defect with potential disease modifying properties. NV1205 is an orally bioavailable small molecule that upregulates the ABCD2 gene. Pharmacological studies in ABCD1 knock-out mice treated with NV1205 have shown that long-term systemic administration of NV1205 results in VLCFA reductions in the central nervous system, adrenal cortex, and blood. The results support the upregulation of ABCD2 by NV1205 to complement the genetic defect as a treatment modality for all phenotypes of X-ALD.
S) Lysosomal Disorders: Mucopolysaccharidoses, Oligosaccharidoses (585 to 676)
585 - Improvement of Diagnostic Technique of MPS VII in Dried Blood Spots
Jaqueline Cé, Melissa Torres Rodrigues, and Janice Coelho
UFRGS, Porto Alegre, RS, Brazil
The mucopolysacharidosis VII is caused by deficiency of the β-glucuronidase enzyme (GUSB). The aim of this work is to miniaturize, correlate and validate the method for measuring the activity of GUSB in 1.2 mm DBS and then determine the biochemical parameters of this enzyme. The technique for the measurement of GUSB activity in 3 mm DBS was adapted to 1.2 mm and the reagents were reduced 4-fold. Correlation tests were performed and after we used for the validation tests: Interassay, Interpersonal and Intraassay. For the optimum pH determination, we used the values of pH 2.0 to 5.4. The substrate curve was performed with 1.25 to 12.5 mM of substrate and according to this analysis, the concentrations 0.25 to 1.50 mM were chosen to determine Km and Vmax (Lineweaver-Burk plot). Comparing the 3.0 x 1.2 mm DBS, we had a significant correlation (Pearson r = 0.7908). This method was validated and the coefficients of variation were: intraassay 9.3%, interassay 11.9%, and interpersonal 9.4%. We observed that pH 4.4 showed higher levels of enzyme activity. Km of GUSB in DBS from healthy subjects was calculated as 1.77 mM and Vmax found was 460.94 nmol/h/mL. These results show that it is possible to measure the activity of GUSB with a smaller DBS diameter and a 4-fold reduction in the volume of the reagents, as has been done with other lysosomal hydrolases (chitotriosidase, alpha-iduronidase, and beta-glycosidase), obtaining the same results from former method. The miniaturization of the MPS VII diagnostic method allows sample saving, which can then be used to screen for other inborn errors of metabolism, and reagents, reducing the cost of the analysis. The results obtained in the validation of the miniaturized method indicate that the three coefficients of variation are within the acceptable value. This demonstrates the accuracy and reproducibility of the method used. The pH of 4.4 was then determined to be the optimum pH of the enzyme. The former technique, with a 3 mm DBS, uses 4.8 pH for the enzymatic assay, the same pH used in the measurement technique of GUSB activity in plasma. For the first time, optimal pH studies were performed to measure enzymatic activity in blood collected on filter paper. The Km of GUSB in leukocytes from healthy subjects was calculated as 1.77 mM and the Vmax found was 460.94 nmol/h/mL. There are no other papers in the literature citing kinetic data for this enzyme, so we cannot compare them. Supported by CNPq.
586 - Ocular Changes in Patients With Mucopolysaccharidosis of Different Forms: 5-Year Experience
Natella Sukhanova
National Scientific and Practical Center of Children's Health, Moscow, Russia
587 - Adult-Onset Diagnosis of Mucopolysaccharidosis (MPS) Type IIIA
Karolina Stepien1, Miranda Splitt2, Detelina Grozeva3, Lucy Raymond3, and Christian Hendriksz1
1Adult Inherited Metabolic Disorders, Salford Royal Nhs Foundation Trust, Salford, Great Britain
2Institute of Genetic Medicine, International Centre for Life, Newcastle Upon Tyne, Great Britain
3Cambridge Institute for Medical Research, University of Cambridge, Cambridge, Great Britain
Mucopolysaccharidosis IIIA (Sanfilippo A) is an autosomal recessive disorder caused by the SGSH gene mutation. Clinical features include severe neurologic degeneration, developmental delay and behavioral problems between 2-6 years of age, with death by the age of 30 years. The Genetics of Learning Disability (GOLD) Study performed whole exome sequencing (within UK10 K study) in patients ascertained through UK Genetics Centers having Intellectual Disability of unknown etiology. 41-year old man who presented with mild learning difficulties was diagnosed with MPS IIIA at 40 years of age. His brother, 43 years old, is severely affected with the progressive course of the condition; disabled, nonambulant, and nonverbal. The GOLD study revealed that both brothers were compound heterozygous for the c.220C>T p.(Arg74Cys) and c.1063G>A p.(Glu355Lys) variants. Sulfaminidase activity was deficient at 0.2 nmol/mg/17 hrs. Urine GAGs were raised at 13.6 mg/mmol creatinine. In childhood, his problems started from ear infections at the age of 5. Despite the need for some support in primary and secondary school, he completed his education without major problems. He had remained physically active until his late 30s when he started requiring some support from carers. He was diagnosed with retinitis pigmentosa following impairment of night vision in his late teens. He also suffers from hearing impairment. On examination, he walked independently (height: 179 cm, BMI 22.8 kg/m2). There were no obvious skeletal abnormalities (apart from some mildly broad wrists) or behavioral disturbance. MPS IIIA may present only with learning disability with no significant clinical morbidities. Patients affected with classical mutations are able to live to their 40s. Both brothers are some of the longest living siblings with MPS IIIA. The patient was mildly affected while his brother who has the same pathogenic variant has followed a more typical course. This case shows the importance of considering ultra-rare disease diagnosis in nonclassical patients.
588 - Development of a Scoring System in the Diagnosis of Mucopolysaccharıdoses
Selda Bülbül1, Mehmet Gunduz2, Nur Arslan3, and Engin Kose3
1Kirikkale University Medical School, Ankara, Turkey
2Ankara Child Education & Research Hospital, Division Metabolic Diseases, Ankara, Turkey
3Dokuz Eylul University Department of Pediatrics, Pediatric Nutrition and Metabolism, İzmir, Turkey
589 - Clinical, Biochemical, and Molecular Features of Iranian Families With Mucopolysaccharidosis
Vahid R. Yassaee1, Shadab Salehpour2, Feyzollah Hashemi-Gorji1, Alireza Rezayi2, Mohammad Miryounesi1, and Zeinab Ravesh1
1Genomic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
2Department of Pediatrics, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
590 - Clinical and Genetic Characteristics of Mucopolysaccharidosis Type IV A (Morquio A Syndrome) in Russian Patients
Alla Semyachkina1, Elena Voskoboeva2, Ekaterina Nikolaeva1, and Elena Zakharova2
1Research and Clinical Institute of Pediatrics Named After Yuri Veltischev of The Pirogov University, Moscow, Russia
2Research Centre for Medical Genetics of the Russian Academy of Sciences, Moscow, Russia
The purpose of the study is to reveal clinical and genetic characteristics of patients with Morquio A syndrome based on the DNA diagnostics method which was first developed in Russia for this orphan disease. We examined 14 patients with Morquio A syndrome aged from 2 to 34 years (the sex ratio is 1:1). All of the patients had typical signs of the “Morquio-like” phenotype such as dwarf growth, keeled thoracic deformation, valgus knee joint, short neck, increased volume and stiffness of large joints and hypermobility of small (interphalangeal) joints, rough features, moderate hepatosplenomegaly, corneal opacity, and hearing loss. The DNA diagnostics was performed in 8 patients. In 3 probands the second mutation in the GALNS gene has not yet been determined. The character of 13 identified mutations was as follows: 7 missense mutations; 2 splice site mutations and 4 deletions found in 2 siblings in the homozygous state (del ex 14/del ex 14 and c.1516 delA/c.1516 delA). Clinical symptomatology: out of 8 children examined, 2 had severe symptoms of muscular hypotonia, which was most likely formed due to the narrow cervical canal caused by deposition of keratan sulfate. These children were capable of moving only with a wheelchair. The GALNS gene analysis revealed missense mutations p.Gly44Val/p.Trp230Arg and P.Cys165Tyr/p.Asp447His. In two patients with the GALNS gene deletion, the disease was characterized by severity and decreased intelligence, which, as a rule, is not typical of patients with Morquio A syndrome. The child with GALNS gene deletion c.1516 delA/c.1516 delA died suddenly at the age of 2.5. According to the anamnesis, his older sister died also suddenly at the age of 10 with the same symptomatology. The autopsy was not conducted due to religious beliefs of the family. Thus, this research allowed us to detect clinical and genetic relationships in patients with mucopolysaccharidosis type IV A.
591 - Natural History and Clinical Assessment of Taiwanese Patients With Mucopolysaccharidosis III
Hsiang-Yu Lin1, Shuan-Pei Lin1, Chih-Kuang Chuang1, Pao Chin Chiu2, Fuu-Jen Tsai3, Dau-Ming Niu4, Shio Jean Lin5, Wuh-Liang Hwu6, and Tung-Ming Chang7
1Mackay Memorial Hospital, Taipei, Taiwan
2Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
3China Medical University Hospital, Taichung, Taiwan
4Taipei Veterans General Hospital, Taipei, Taiwan
5Chi Mei Medical Center, Tainan, Taiwan
6National Taiwan University Hospital, Taipei, Taiwan
7Changhua Christian Children's Hospital, Changhua, Taiwan
Mucopolysaccharidosis type III (MPS III), or Sanfilippo syndrome, is caused by a deficiency in one of the four enzymes involved in the lysosomal degradation of heparan sulfate. Four MPS III types have been recognized, characterized by a large phenotypic heterogeneity. MPS III has a variable age of onset and variable rate of progression. A retrospective analysis was carried out of 28 patients with MPS III (3 with IIIA, 23 with IIIB, and 2 with IIIC; 15 males and 13 females; mean age, 10.1 ± 5.7 years; median age, 8.2 years; age range, 2.7-26.5 years) seen in 6 medical centers in Taiwan from January 1996 through March 2017. The diagnosis of MPS III was confirmed by measurement of enzymatic activities of particular lysosomal hydrolases in leukocytes or skin fibroblasts and/or two-dimensional electrophoresis of urinary glycosaminoglycans. The mean age of confirmed diagnosis was 4.7 ± 2.1 years. The mean z scores for height, weight, and BMI at the time of the latest medical records were −0.47 ± 1.97, 0.02 ± 1.49, and −0.17 ± 0.95, respectively. Both z scores for height and weight were negatively correlated with age (r = −0.693 and −0.718, respectively; P < .01). The most prevalent clinical manifestations were speech delay (100%), mental retardation (100%), hirsutism (93%), hyperactivity (79%), coarse face (68%), sleep disorders (61%), and hepatosplenomegaly (61%). Ten patients (36%) had epilepsy, and the mean age of the first time of seizure attack was 10.7 ± 4.8 years. Thirteen patients (46%) experienced at least one surgical procedure. The most prevalent surgical interventions were adenoidectomy (11%), tonsillectomy (11%), supraglottoplasty (11%), inguinal hernia repair (11%), percutaneous endoscopic gastrostomy (11%), ear tube insertion (7%), and epiphyseal surgery (4%). The most prevalent cardiac valve abnormalities were tricuspid regurgitation (72%) and mitral regurgitation (67%). At the time of the present study, 7 of 28 patients have passed away at the mean age of 13.0 ± 3.0 years. An understanding of the natural history involved in MPS III may allow early diagnosis of the disease. All affected patients experienced significant functional limitations, and adequate evaluations and timely management may improve their quality of life. These findings and the follow-up data can be used to develop quality of care strategies for patients with MPS III.
592 - The Levels of Urinary Glycosaminoglycans in Patients With Mucopolysaccharidoses and the Effects of Enzyme Replacement Therapy Detected by Liquid Chromatography-Tandem Mass Spectrometry
Hsiang-Yu Lin1, Shuan-Pei Lin1, Chih-Kuang Chuang1, Sung-Fa Huang1, Tzu-Lin Chen1, Yu-Shan Wang1, and Dau-Ming Niu2
1Mackay Memorial Hospital, Taipei, Taiwan
2Taipei Veterans General Hospital, Taipei, Taiwan
The Mucopolysaccharidoses (MPSs) are a group of rare lysosomal storage disorders characterized by the accumulation of glycosaminoglycans (GAGs) in various tissues and organs. The dimethylmethylene blue (DMB) spectrophotometric method commonly used in most biochemical genetics laboratories relies on a non-specific total GAG analysis which has led to false positive results, and even false negative results (mainly for MPS III and IV patients). The purpose of this study was to validate a reliable liquid chromatography/tandem mass spectrometry method (LC-MS/MS) for the urine quantitation of three GAGs [dermatan sulfate (DS), heparan sulfate (HS), and keratin sulfate (KS)] to help make correct diagnosis of MPS and evaluate the effectiveness of enzyme replacement therapy (ERT). Sixty-six patients with MPS (age range, 0.7 to 49.3 years; 14 with MPS I, 14 with MPS II mild form, 9 with MPS II severe form, 11 with MPS III, 10 with MPS IVA, and 8 with MPS VI) were evaluated of their three urinary GAGs (DS, HS, and KS) by LC-MS/MS method, as well as non-specific total urinary GAG by DMB spectrophotometric method. The mean levels of DS (reference < 1.68 μg/mL) were 194.6, 118.0, 253.8, and 108.9 μg/mL for MPS I, MPS II mild form, MPS II severe form, and MPS VI, respectively. The mean levels of HS (reference < 3.88 μg/mL) were 6.2, 7.3, 446.6, and 260.7 μg/mL for MPS I, MPS II mild form, MPS II severe form, and MPS III, respectively. The mean level of KS (reference < 17.8 μg/mL) of MPS IV was 401.0 μg/mL. The mean DMB ratios were 601.0, 367.0, 913.8, 654.4, 142.0, and 853.7 for MPS I, MPS II mild form, MPS II severe form, MPS III, MPS IV, and MPS VI, respectively. Among these 64 patients, 20 patients with mental retardation had higher levels of HS, compared with 44 patients without mental retardation (328.8 vs. 4.1, p)
593 - Mutation in the VPS33A Affects Metabolism of Glycosaminoglycans: A New Type of Mucopolysaccharidosis With Severe Systemic Symptoms
Hidehito Kondo1, Nadezda Maksimova2, Takanobu Otomo1, Kaori Irahara1, Yusuke Hamada1, Keiichi Ozono1, and Norio Sakai1
1Osaka University, Suita, Japan
2North East Federal University, Yakutsk, Russia
Mucopolysaccharidoses (MPS) are a group of genetic deficiencies of lysosomal enzymes that catabolize glycosaminoglycans (GAG). Here we report a novel MPS-like disease caused by a specific mutation in the VPS33A gene. We identified several Yakut patients showing typical manifestations of MPS: coarse facial features, skeletal abnormalities, hepatosplenomegaly, respiratory problems, mental retardation, and excess secretion of urinary GAG. However, these patients could not be diagnosed enzymatically as MPS. They showed extremely high levels of plasma heparan sulfate (HS, one of GAG); 60 times the normal reference range and 6 times that of MPS patients. Additionally, most patients developed heart, kidney, and hematopoietic disorders, which are not typical symptoms for conventional MPS, leading to a fatal outcome between 1 and 2-years old. Using whole exome and Sanger sequencing, we identified homozygous c.1492C>T (p.Arg498Trp) mutations in the VPS33A gene of 13 patients. VPS33A is involved in endocytic and autophagic pathways, but the identified mutation did not affect either of these pathways. Lysosomal over-acidification and HS accumulation were detected in patient-derived and VPS33A-depleted cells, suggesting a novel role of this gene in lysosomal functions. We hence propose a new type of MPS that is not caused by an enzymatic deficiency.
594 - Enzyme Replacement Therapy Recovers the Testicular Interstitium With Progressive Damage Observed in the Mucopolysaccharidosis Type I (MPS I) Animal Model
Cinthia Nascimento1, Guilherme Baldo2, Esteban Gonzalez2, Gabriela Pasqualim2, Odair Aguiar3, and Vânia D’Almeida1
1Universidade Federal de São Paulo, São Paulo, SP, Brazil
2Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
3Universidade Federal de São Paulo, Santos, SP, Brazil
Mucopolysaccharidosis type I (MPS I) is a lysosomal storage disease caused by a dysfunction of alpha-L-iduronidase (IDUA), a lysosomal hydrolase that degrades glycosaminoglycans: heparan and dermatan sulfate. MPS I is a progressive and multisystemic disorder that affects many organs and tissues as a consequence of the unsuitable storage of substrates inside lysosomes. In order to evaluate the effect of MPS I progression on male reproductive tract, we performed testicular histological sections of Idua−/− C57BL/6 J mice with different ages: 3, 6, 8, and 12-month-old. Six and 8-month-old Idua−/− mice were submitted to enzyme replacement therapy (i.v. injection of 1.2 mg/kg of Laronidase® every 2 weeks): one group treated since neonatal period and other group from 6-8 months old. We also treated an Idua−/− group with cathepsin B inhibitor (10 mg/kg/day i.p.) from 2-6 months old, since high levels of cathepsin B are associated to the MPS I histopathology, such as cell death and inflammation. We performed testicular histological sections in all groups, counted Leydig and interstitial vacuolated cells, when present. Interstitium is the most damaged testicular compartment of Idua−/− mice, with numerous vacuolated cells, that are more frequent in 6-month-old compared to 3-month-old Idua−/− (P = .008) and in 12-month-old compared to 6-month-old Idua−/− mice (P = .023). We found less vacuolated cells in groups submitted to enzyme replacement therapy started at either neonatal period and adult age, compared to 6-month-old untreated mice (P = .009; P = .014, respectively). No difference was found in Idua−/− mice treated with cathepsin B inhibitor. Leydig cells, the major source of testosterone, were not quantitatively altered among all groups. Plasma testosterone and progesterone, previously accessed in 6-month-old Idua−/− untreated mice, were similar to those from same aged Idua+/+. We concluded that the absence of IDUA progressively influences on the vacuolization of a specific cell type located in testicular interstitial compartment and does not influence on Leydig cell number. Under enzyme replacement therapy, the interstitial compartment is recovered, regardless the period of treatment beginning.
595 - Individual Heat Map Assessments Demonstrate ERT Treatment Response in Highly Heterogeneous MPS VII Study Population
Christine Haller1, Wenjie Song1, Tricia Cimms1, Chao-Yin Chen1, Chester B. Whitley2, Raymond Y. Wang3, Mislen Bauer4, and Paul Harmatz5
1Ultragenyx Pharmaceutical Inc., Novato, CA, USA
2University of Minnesota, Minneapolis, MN, USA
3Children's Hospital of Orange County, Orange, CA, USA
4Miami Children's Hospital, Miami, FL, USA
5Ucsf Benioff Children's Hospital Oakland, Oakland, CA, USA
Sly syndrome (mucopolysaccharidosis, MPS VII) is an ultra-rare, progressively debilitating, life threatening lysosomal disease in which patients are deficient in the enzyme, beta-glucuronidase (GUSB). Vestronidase alfa (UX003) is a recombinant human GUSB being developed as a potential enzyme replacement therapy for MPS VII. The Phase 3 Study was a randomized, placebo-controlled, Blind-Start study of 4 mg/kg vestronidase alfa given every-other-week for 24-48 weeks which incorporated several innovative elements to address drug development challenges associated with ultra-rare, life-threatening diseases. Because of extreme disease rarity, eligibility criteria were broad to be inclusive of all available patients thus resulting in a highly heterogeneous study population with variable clinical manifestations and physical +/or cognitive limitations. To provide an integrated view of the diverse data, the changes from baseline in study assessments for each subject were grouped into 3 functional categories for evaluation: Mobility, Fatigue, Fine Motor + Self-care, and analyzed as subject-level heat maps. Mobility included the 6-minute walk test, 3-minute stair climb test, BOT-2 gross motor function subtests, and patient reported outcome (PRO) data related to movement, pain, and ambulation. Fatigue included the PedsQL Multidimensional Fatigue Scale scores and additional PRO results related to fatigue and energy. Fine-Motor + Self-care domains of the PRO instruments included eating, dressing, hygiene, and caregiver assistance and grouped with BOT-2 fine motor function subtests because improved use of arms and hands is expected to improve activities such as self-grooming and feeding. Overall, 10 of 12 subjects showed improvement in at least one functional category: 4 improved in Mobility, 5 improved in Fatigue and 3 improved in Fine Motor + Self-care. Two subjects improved in 2 or more categories and 2 did not show clear improvement in any functional category. Both severely and mildly affected subjects improved in clinical tests, PRO results or both. By grouping related clinical domains including functional test results and PRO assessments and displaying over the entirety of the study in a heat map, both worsening and improvement on placebo and active treatment could be visualized and an assessment of treatment response made for each subject. This comprehensive per-subject approach may be useful in other rare diseases with complex, highly variable clinical presentations.
596 - Oligosacchariduria Profiles by MALDI-TOF Mass Spectrometry and Post-Analytical Interpretation Using Multivariate Pattern Recognition Software
Kim Nickander, Dimitar Gavrilov, Dietrich Matern, Devin Oglesbee, Piero Rinaldo, Silvia Tortorelli, and Kimiyo Raymond
Mayo Clinic, Rochester, MN, USA
Oligosacchariduria occurs in many lysosomal storage diseases involving enzyme deficiencies causing an accumulation of oligosaccharides in tissues and increased excretion in urine. In addition to glycoproteinoses, mucolipidoses, mucopolysaccharidoses, and some congenital disorders of glycosylation can also be identified by the analysis of urine oligosaccharides. Due to the broad spectrum of clinical presentations and biochemical phenotypes, the clinical significance of complex oligosaccharide profiles (60 species and 1223 calculated ratios) generated by MALDI-TOF mass spectrometry is achieved by automated post-analytical interpretation using a custom-made multivariate pattern recognition software, Collaborative Laboratory Integrated Reports (CLIR; https://clir.mayo.edu). Oligosaccharides are prepared by permethylation (modified from Xia et al, 2013). Validation included specimens from confirmed patients and additional cases have been detected and confirmed prospectively in patient samples submitted for diagnosis affected with α-mannosidosis (N = 4), β-mannosidosis (N = 1), fucosidosis (N = 2), Pompe disease (N = 7), GM1 gangliosidosis (N = 5), MPSIVB, (N = 1), GM2, Sandhoff disease (N = 2), Schindler disease (N = 1), aspartylglucosaminuria (N = 2), and NGLY1-CDG (N = 11), all shown to have a specific profile pattern leading to the biochemical diagnosis of a single condition and hence recommendation of targeted confirmatory analysis. Mucolipidoses (MLII, N = 7; MLIII, N = 5), sialidosis (N = 4), and galactosialidosis (N = 3) showed abnormal overlapping profiles, yet disease specific patterns. Overlapping oligosaccharide profiles within mucopolysaccharidoses (MPSI, N = 3; MPSII, N = 6; MPSIII, N = 2; MPSIVA, N = 3; MPSVI, N = 3) lead to less accurate resolution of diagnostic options via this platform, but it is recommended to be confirmed by glucosaminoglycan (GAG) analysis. CLIR has been updated with >1100 reference data and assists to quickly identify abnormal specimen patterns to aid the clinician in further testing. Our multiplex approach allows us to diagnose oligosaccharidoses, mucopolysaccharidoses, CDG-IIb, NGLY1-CDDG, and sulfatiduria in a small urine sample (<2 mL).
597 - Design and Rationale of Ongoing Observational and Treatment Studies for BMN 250, a Novel Enzyme Replacement Therapy for Sanfilippo Syndrome Type B (MPS IIIB)
Aji Nair, Stephen Maricich, Hua Yu, and Steve Kent
Biomarin Pharmaceutical Inc, Novato, CA, USA
Sanfilippo Syndrome Type B (MPS IIIB) is a lysosomal storage disease characterized by rapidly progressing neurological decline, due to deficiency of the α-N-acetylglucosaminidase (NAGLU) enzyme. To determine whether treatment effects are clinically meaningful, it is critical to understand Sanfilippo B disease progression, particularly cognitive decline, in untreated patients. Development quotient (DQ) derived from scores on either one of two cognitive tests (BSID or KABC) has been validated as a cognitive measure in children with Sanfilippo A. While studies have demonstrated marked changes in DQ in younger MPS IIIA patients, information regarding DQ trajectory in young Sanfilippo B patients is scarce. BMN 250-901 (NCT02493998) is an observational study designed to quantify the progression of Sanfilippo B over time in affected children primarily aged 1-5 years at baseline and with relatively preserved cognitive function, and to correlate changes in clinical features of the disease, in particular changes in DQ, with MRI characteristics and biochemical markers of disease burden. BMN 250-902 is an additional observational study designed to capture disease trajectory across the spectrum of Sanfilippo B, including patients of all ages and all degrees of cognitive impairment. Concurrently, the BMN 250-201 treatment study (NCT02754076) is also underway using BMN 250 (NAGLU-IGF), a novel enzyme replacement therapy designed to restore functional NAGLU activity to the brain. Part 1 of BMN 250-201 is a dose-escalation period to establish safety; Part 2 is a dose-expansion period and consists of patients from participating sites rolling over from Part 1 and the BMN 250-901 observational study. Efficacy will be assessed by comparing changes in disease progression in the BMN 250-901 study vs. changes observed in Part 2 of BMN 250-201. Studies BMN 250-901, BMN 250-201 and BMN 250-902 are currently enrolling. Data from the BMN 250 clinical development program will provide valuable information on the natural history of untreated Sanfilippo B patients and the efficacy and safety of BMN 250. This abstract was previously presented at the 2017 LDN WORLD Symposium.
598 - Preliminary Safety and Pharmacodynamic Response Data From a Phase 1/2 Study of ICV BMN 250, a Novel Enzyme Replacement Therapy for the Treatment of Sanfilippo Syndrome Type B (MPS IIIB)
Nicole Muschol1, Maureen Cleary2, Maria Luz Couce3, Aji Nair4, Heather Cahan5, Anita Grover4, Stephen Maricich4, Andrew Melton4, Lynn Smith4, and Maria Jose de Castro Lopez3
1University Medical Center Hamburg-Eppendorf, Hamburg, Germany
2Great Ormond Street Hospital, London, United Kingdom
3Hospital Clínico Universitario de Santiago, A Coruna, Spain
4Biomarin Pharmaceutical Inc, Novato, CA, USA
5Biomarin Pharmaceutical Inc, Novoto, CA, USA
Sanfilippo Syndrome Type B (MPS IIIB) is a lysosomal storage disorder caused by deficiency of the α-N-acetylglucosaminidase (NAGLU) enzyme and subsequent heparan sulfate (HS) accumulation in the brain. Sanfilippo B patients display progressive neurocognitive decline and typically do not live past the second or third decades of life. BMN 250 (NAGLU-IGF2) is a novel enzyme replacement therapy (ERT) for Sanfilippo B consisting of NAGLU enzyme fused to insulin-like-growth factor 2 (IGF2) to enhance lysosomal targeting. This report presents preliminary results from the first human study of BMN 250 (BMN 250-201; NCT02754076). BMN 250-201 is a phase 1/2, open-label study with two parts. Part 1 consists of 2 dose-escalation periods (≥4 weeks) of intracerebroventricular (ICV) BMN 250 administered as an isovolumetric bolus infusion QW. Subjects from Part 1 and from an ongoing observational study of Sanfilippo B patients (BMN 250-901; NCT02493998) will continue to Part 2, a 48-week treatment period to examine efficacy/safety at the maximum tolerated tested dose. For enrollment into Part 1, 1- to 10-year-old subjects with Sanfilippo B must have deficient NAGLU activity at screening. Three subjects have received ≥8 30 mg BMN 250 doses QW and ≥3 100 mg doses QW. All subjects demonstrated marked and sustained decreases in cerebrospinal fluid (CSF) total and disease-specific HS levels relative to baseline. BMN 250 was well tolerated with no treatment-emergent serious adverse events. These findings demonstrate that BMN 250 can be safely administered into brain ventricles via isovolumetric bolus infusion and that this treatment approach leads to a marked pharmacodynamic response in the CNS of Sanfilippo B patients. High levels of HS clearance are associated with improvement in markers of neuronal damage in preclinical models, suggesting potential translation into clinical benefit. Completion of BMN 250-201 will provide further information on the efficacy and safety of BMN 250. This abstract was presented at the 2017 LDN WORLD Symposium.
599 - Twelve novel GUSB Mutations and genotype-phenotype correlation in Mucopolysaccharidosis VII (MPS VII) patients
Qais Abu Ali1, Wenjie Song1, Sean Daugherty1, Andrea Schatz1, Heather Lau2, Cláudia Dias da Costa3, Thierry Levade4, Guy Touati5, Deborah Marsden1, Christine Haller1
1Ultragenyx Pharmaceutical, Inc., Novato, CA, USA
2New York University Lagone Medical Center, New York, NY, USA
3Centro Hospitalar Lisboa Norte Epe, Lisbon, Portugal
4Institut Fédératif de Biologie, Chu Toulouse, France
5Hôpital Des Enfants, Chu Toulouse, France
MPS VII is a clinically heterogeneous, ultra-rare, autosomal recessive lysosomal disease in which patients are deficient in beta-glucuronidase enzyme (GUS). Nearly fifty unique MPS VII-causing mutations in GUSB gene have been reported. In this study, we present twelve novel GUSB mutations and provide potential genotype-phenotype correlation. Twenty-three MPS VII patients were enrolled in early access programs and clinical studies investigating recombinant human GUS, vestronidase alfa (UX003), as a potential enzyme replacement therapy (ERT). GUSB testing results were available on 74% of patients (17/23). 65% (11/17) were male, 35% (6/17) female; 35% (6/17) were Hispanic, 29% (5/17) Caucasian, 18% (3/17) Asian, and 6% (1/17) each for African American, native Brazilian and unknown ethnicity. 65% of patients (11/17) were unrelated, in addition to three sets of non-twin siblings. All tested patients harbored at least two mutations. Overall, twenty different GUSB mutations were identified, all being missense. 60% (12/20) were novel mutations (c.1A>G, p.G97A, p.E141A, p.H142Y, p.W288 L, p.N379 S, p.M430 T, p.S485F, p.V496 L, p.G512 R, p.W587 S, p.I608 M). 59% of patients (10/17), including two of three sibling pairs, were heterozygous for at least one novel mutation, and 30% of these patients (3/10) were compound heterozygous for two novel mutations. 82% of patients (14/17) harbored at least one previously published mutation. To assess potential genotype-phenotype correlation, an individual clinical assessment of disease severity at baseline was done, considering dysmorphic, clinical, diagnostic and functional assessments including walking ability and patient reported outcomes. All patients (4/4) heterozygous for these novel mutations: c.1A>G, p.G512 R, p.W288 L, p.S485F, p.V496 L, p.W587 S and p.I608 M exhibited an overall severe phenotype. All patients (4/4) heterozygous for these novel mutations: p.M430 T, p.G97A, p.E141A and p.H142Y exhibited an overall mild phenotype. One sibling pair harbored p.N379 S novel mutation, and overall phenotype was mild for one sibling but severe for the other. Our results add twelve novel GUSB mutations to previously reported genotype data, and provide further evidence that genetic heterogeneity could contribute to MPS VII clinical heterogeneity. Genotype-phenotype correlation will benefit from future studies aimed at understanding possible role of various genotypes in potential response to investigational ERT in MPS VII patients.
600 - First Report of an Exclusively Japanese GUSB Mutation in a Non-Japanese MPS VII Patient
Qais Abu Ali1, Sean Daugherty1, Andrea Schatz1, Christine Haller1, and Pranoot Tanpaiboon2
1Ultragenyx Pharmaceutical, Inc., Novato, CA, USA
2Children's National Health System, Washington, DC, USA
Mucopolysaccharidosis VII (MPS VII) is an ultra-rare, autosomal recessive lysosomal disease characterized by deficiency in beta-glucuronidase enzyme. Over sixty different mutations distributed along GUSB gene have been reported to date. Mutation spectrum includes missense, nonsense, deletions and splice site mutations. Population specific GUSB mutations have been reported, with Pro408Leu and Pro415Leu being observed only in Mexican patients and Ala619Val only in Japanese patients. We present a severely affected MPS VII patient from Thailand with no reported Japanese ancestry, who harbors Ala619Val GUSB mutation. This patient is a female product of nonconsanguineous Thai parents from a rural area and G2P1 mother, who was born prematurely at 32 weeks of gestation. Prenatal history was significant for hydrops fetalis detected by ultrasound. Post-natal, neonatal and childhood history was significant for short stature, poor weight gain, mild coarse facial features, macrocephaly, corneal clouding, hypertelorism, obstructive sleep apnea, respiratory failure, cardiac arrest, mild hepatomegaly, umbilical hernia, kyphoscoliosis, hip dysplasia, congenital club feet, cervical cord compression, global developmental delay and wheelchair confinement. Comprehensive diagnostic workup including the following was obtained: Karyotype showed 46, XX; skeletal survey showed dysostosis multiplex mainly involving hip and cervical spine; echocardiograms showed malformed atrio-ventricular annulus and aortic root with resolution of pulmonary stenosis and atrial septal defect; MRI spine showed cervicomedullary and C7-T2 compression for which the family declined neurosurgical intervention. At age of 9.5 years, further diagnostic workup confirmed MPS VII. Leukocyte beta-glucuronidase enzyme was deficient (4.45 nmol/hr/mg, normal 31.4-224 nmol/hr/mg). GUSB sequencing revealed homozygous c.1856C>T (p.Ala619Val) mutation. Literature review revealed only two other MPS VII patients, both Japanese, harboring Ala619Val mutation which was considered a founder mutation. Follow-up with patient’s family affirmed their Thai but not Japanese ancestry. This report represents a severely affected non-Japanese MPS VII patient carrying the Japanese-specific GUSB Ala619Val mutation.
601 - The Trafficking and Enzymatic Activity Defects of the Beta Galactosidase D151Y Mutant Causing GM1-Gangliosidosis are Correctable by Chemical Chaperones and Reduced Temperature
Fedah Mohamed, Bassam Ali, Lihadh Al-Gazali, and Fatma Al Jasmi
UAE University, Al-Ain, United Arab Emirates
Missense mutations affecting protein stability and folding properties are common in many genetic disorders resulting in low protein half-life, premature degradation, aggregation or retention in the endoplasmic reticulum. GM1-Gangliosidosis, a lysosomal storage autosomal recessive neurological disorder, is associated with more than 115 missense mutations in the GLB1 gene. These mutations cause beta-galactosidase (β-Gal) enzyme deficiency in lysosomes. Pharmaceutical chaperones (PCs) have been proposed to restore the lost function of β-Gal affected by certain missense mutations. PCs are small molecular weight compounds that specifically bind and stabilize the mutated enzymes to promote trafficking and maturation. In this study, an Emirati child has been clinically characterized with GM1-Gangliosidosis who had lost two siblings with the same disorder. Segregation analysis by Sanger Sequencing confirmed the presence of the homozygous c.451G>T mutation resulting in a missense mutation (p.D151Y). Biochemical analysis using the patient’s fibroblasts showed that the mutant protein has retained less than 1.3% of the wild type enzymatic activity. In addition, our data showed that the mutant protein trafficking is defective as evidenced by the exclusive presence of the ER immature in these cells. Initial rescue experiments using glycerol and culturing cells at reduced temperatures promoted the mutated β-Gal maturation and trafficking to lysosomes and increased its residual activity by up to 6 folds. Furthermore, the enzymatic activity of D151Y β-Gal mutant increased to 2-3% of wild type using two different chemical chaperones. These findings raise the possibility of using pharmaceutical chaperones as possible personalized treatments for this disorder.
602 - A Temporal Cluster of Mucopolysaccharidosis Type I in the Region of Sucre and Cordoba, Colombia
Fernando Suarez-Obando1, Ernesto Panesso-Suescun2, John Gamba-Rendón3, and Alfredo Uribe4
1Pontificia Universidad Javeriana, Facultad de Medicina. Instituto de Genética Humana, Bogotá, Colombia
2Universidad de Córdoba, Montería, Colombia
3Sanofi-Genzyme, Bogotá, Colombia
4Universidad de Los Andes, Bogotá, Colombia
603 - A Long-Term Extension Study Evaluating Intrathecal Idursulfase-IT in Children With Hunter Syndrome and Cognitive Impairment
Joseph Muenzer1, Christian Hendriksz2, Margot Stein1, Zheng Fan1, Shauna Kearney3, Johan Horton3, Suresh Vijayaraghavan3, Saikat Santra3, Guirish Solanki3, Luying Pan4, Yuna Wu4, and David Alexanderian4
1University of North Carolina At Chapel Hill, Chapel Hill, NC, USA
2Fymca Medical Ltd, Manchester, United Kingdom
3Birmingham Children's Hospital Nhs Foundation Trust, Birmingham, United Kingdom
4Shire, Lexington, MA, USA
604 - Prenatal Diagnosis Experience of Hunter disease in Argentina
Francisca Masllorens1, Romina Ceci2, Norma Sganzetta1, and Paula Rozenfeld2
1Hospital Nacional Posadas, Buenos Aires, Argentina
2Iifp (Universidad Nacional de La Plata-Conicet), La Plata, Argentina
Prenatal diagnosis of Hunter syndrome (mucopolysaccharidosis type II; MPS II) is preferably achieved in uncultured chorionic villi (CV), as this allows early, rapid and reliable results. The objective of this study is to report the prenatal diagnosis tests carried out in Argentina for Hunter disease. Chorionic villi samples were obtained from heterozygote women (n = 6) for Hunter disease. Samples were processed to carry out enzymatic assays for Iduronate sulfatase and karyotyping to establish fetal sex. Whenever the mutation was previously known molecular genetic test was performed. Pregnant patients from families with MPSII disease from different places of Argentina were referred for genetic counseling and prenatal testing. A total of 6 CV samples were obtained between 12-15 weeks of gestation, 3 fetuses were male and 3 females. Two of the male cases showed deficient IDS activity, and in one, the diagnosis was also confirmed by genetic molecular test. Among female fetuses two were heterozygous and the other one did not carry the family mutation.
605 - Evaluation and Impact on the Quality of Life of Patients With Mucopolysaccharidosis IV-A (Morquio A) at the Colombian Southwestern
Jose Maria Satizabal Soto and Lina Johanna Moreno Giraldo
Universidad Del Valle, Cali, Colombia
Mucopolysaccharidosis IVA (MPS IVA; Morquio A syndrome) is a rare autosomal recessive lysosomal storage disorder. The disease is caused by a deficiency of the enzyme N-acetylgalactosamine-6-sulfatase (GALNS), which is responsible for the degradation of the glycosaminoglycans: keratan sulfate and chondroitin-6-sulfate. The Morquio A population is characterized by significant genotypic and phenotypic heterogeneity. There is a wide variability in clinical presentation, disease severity, and rate of progression of symptoms among patients. The clinical manifestations generally result in progressively worsening gait abnormalities, impaired mobility / wheelchair use, limitations in performing daily living activities (ADL), and premature death in the classical phenotype. A study of 28 patients with clinical, enzymatic and molecular diagnosis of MPS-IVA at the Colombian Southwestern (age 3.5-27.3 years). ADL was evaluated using the MPS-HAQ, a 52-question instrument originally developed to assess self-care and mobility in patients with MPS I. MPS-HAQ self-care (27 questions related to eating / drinking, dressing, bathing, grooming, tooth brushing, and toileting): 68% without any difficulty, 11% with some difficulty, 7% with much difficulty, and 14% unable to do. Mobility (12 questions related to dexterity, mobility, walking, stair climbing and gross motor skills): 53% without any difficulty, 11% with some difficulty, 7% with much difficulty, and 29% unable to do. And the extent of required caregiver assistance in the performance of these activities (13 questions): 18% patients perform activities without difficulty, 14% with some difficulty, 25% with much difficulty, and 43% unable to do. A significant (−0.75 P < .01) correlation was found between age and total score on the MPS-HAQ. Our study showed that the greatest deviations from a healthy population were seen in domains of pain / discomfort and mobility. Problems with self-care, wheelchair use, or usual activities were also critical factors affecting HRQoL. Regular assessments of QoL and ADL are recommended in order to assess the risk of morbidity and mortality attributed to the disease.
606 - Reactive Nitrogen Species and Inflammatory Biomarkers in Mucopolysaccharidosis Type II Patients Treated With Enzyme Replacement Therapy
Carlos Eduardo Diaz Jacques1, Camila Delgado1, Tatiane Hammerschmidt1, Carolina Souza2, Roberto Giugliani1, and Carmen Regla Vargas1
1Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
2Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
Mucopolysaccharidosis II (MPS II) is an X-linked lysosomal storage disorder caused by a deficiency of iduronate-2-sulfatase activity. This leads to an abnormal storage of glycosaminoglycans (GAG) in tissues and body fluids. It is known that GAG and oligosaccharides fragments can act as direct activators of pathological cascades, increasing proinflammatory cytokines production. Moreover, reactive nitrogen species (RNS)—such as nitric oxide (NO), nitrogen dioxide radical, and peroxynitrite—can cause a variety of cellular damages, and also lead to the activation of inflammatory signaling pathways. In this work, we evaluated the RNS and proinflammatory cytokines production in long-term idursulfase-treated MPS II patients. Urinary nitrate/nitrite, and plasmatic NO, IL-1β, and TNF-α were measured in 8 MPS II patients [mean age: 17.1 years-old; mean time on ERT: 5.2 years (range: 1.5-7.0 years)] and in 10 healthy age-matched individuals (control group). Nitrate/nitrite and NO contents were assessed by Griess reaction methods. IL-1β and TNF-α plasmatic concentrations were measured using ELISA assays. Our results showed that treated MPS II patients present higher levels of RNS in both plasma and urine, compared to the control group. Furthermore, proinflammatory cytokines concentrations were found increased in these patients. It was also observed a significant positive correlation between plasmatic IL-1β and NO concentrations. These results evidence that, despite the long-term treatment with enzyme replacement therapy, MPS II patients present a disruption of inflammatory and nitrative status, and possibly these pathophysiological mechanisms are associated. Considering the deleterious systemic effects of chronic inflammation and redox imbalance, our results suggests that the use of anti-inflammatory and antioxidant drugs may be an important complementary strategy in MPS II treatment.
607 - Neuroradiological Findings and its Correlation With the Cognitive Status and Phenotype in Patients With Mucopolysaccharidosis I and II
Luz Maria Sanchez-Sanchez, Pamela Lozano-Montes, and Mario Alberto de La Portilla-Villanueva
Umae 25, Monterrey, Mexico
608 - Efficacy of Genistein in MPS III Patients From India and Pakistan
Anil Jalan1, Neelam Yadav1, Gauri Gaikwad1, Ketki Kudalkar1, Rishikesh Jalan1, Durga Shinde1, Monal Borugale1, Rasika Tawde1, Caudia Cozma2, Sabriana Eichler2, Arndt Rolf3, Susanne Zielke3, and Hani Rao4
1Navi Mumbai Institute of Research in Mental and Neurological Hanidcap, Navi Mumbai, India
2Centogene Ag, Institute of Rare Diseases, Rostock, Germany
3Albrecht Kossel Institute, Medical Faculty University of Rostock, Rostock, Germany
4Medgen Services, Islamabad, Islamabad, Pakistan
609 - Spectrum of LSDs: An Experience of 158 Affected Individuals From India
Anil Jalan1, Ketki Kudalkar1, Rishikesh Jalan1, Durga Shinde1, Monal Borugale1, Rasika Tawade1, Neelam Yadav1, Gauri Gaikwad1, Claudia Cozma2, Sabrina Eichler2, Arndt Rolfs3, and Susanne Zielke3
1Navi Mumbai Institute of Research in Mental and Neurological Hanidcap, Navi Mumbai, India
2Centogene Ag, Institute of Rare Diseases, Rostock, Germany
3Albrecht Kossel Institute, Medical Faculty, University of Rostock, Rostock, Germany
610 - A Case Series of Twins With Mucopolysaccharidoses
Dimple Nagrani and Damayanti Rusli Sjarif
Cipto Mangunkusumo Hospital, Jakarta, Indonesia
611 - Interest of Early Treatment With Laroniadase in MPS I Moroccan Experience of the Military Hospital of Rabat
Nouzha Dini
Military Hospital, Rabat, Morocco
It is difficult to evaluate the efficacy of the enzyme replacement therapy in MPS type 1 because of the heterogeneity of the phenotypes. However, the follow-up of siblings under treatment allows us to conclude the importance of early treatment at the beginning of the treatment. Our work aims to share our experience in the therapeutic management of MPS1. We collected 7 patients over a period of 8 years, benefiting from full coverage social security, all Hurler-Schei phenotypes, under treatment with the replacement enzyme (Laronidase: Aldurazyme®) except one patient who died at the age of 9 just before treatment. Four patients come from two families and therefore two brothers and then one brother and one sister. The follow-up of these patients and especially of siblings allowed us to conclude that the earlier the treatment is started the better the results are as well on the stability of the initial lesions especially skeletal, as on the improvement of the clinical symptoms.
612 - High Incidence of Alpha-Mannosidosis in the State of Rio de Janeiro—Brazil?
Fernanda Scalco1, Patricia Correia2, Ana Carolina Esposito2, Anneliese Barth2, Dafne Horovitz2, Juan Llerena2, and Maria Lucia Oliveira1
1Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
2Instituto Fernandes Figueira-Fiocruz, Rio de Janeiro, RJ, Brazil
α-Mannosidosis is a rare autosomal recessive, lysosomal storage disorder caused by deficient activity of lysosomal α-mannosidase (MAN2B1), with an estimated prevalence of 1: 500 000. Lack of this enzyme results in accumulation of undigested oligosaccharides and patients accumulate mannose-containing oligosaccharides in tissues and body fluids. LABEIM (Laboratory of Inborn Errors of Metabolism) in Rio de Janeiro state received in 25 years, 11.500 patients with suspected metabolic disease, having diagnosed 6 cases of α-mannosidosis. This number of cases in relation to total cases reported in Brazil suggest that this disease may not be so rare in the state. Of these six cases, five are female and one male, from four different families. In common, all patients are alive, manifested recurrent infections, coarse facies, skeletal abnormalities, cognitive, and motor and hearing impairment. Two families are consanguineous, with two affected in each of them. Symptoms appeared in early age and were gradually progressive. Four patients and their families come from northeastern Brazil, from 2 counties in Paraiba and Bahia, with Portuguese ancestry. The other patients were born in Rio de Janeiro, a Portuguese colonization state, and each of them has a grandfather who migrated from the Northeast, also from Paraiba and Bahia. These data suggest a possible founder effect in the northeastern region of Brazil, probably of Portuguese origin. The molecular study of our patients, not yet undertaken, will be needed to prove this hypothesis.
613 - Coexistence of Mucolipidosis Type III With Trimethylaminuria in a 4.5 Iranian Boy
Shadab Salehpour1, Somayeh Setavand2, Vahid R. Yassaee1, and Seyed Hasan Tonekaboni3
1Shahid Beheshti University of Medical Sciences, Genomic Research Center, Tehran, Iran
2Genomic Research Center, Tehran, Iran
3Hahid Beheshti University of Medical Sciences, Mofid Children Hospital, Tehran, Iran
Mucolipidosis type III α/β (ML III α/β) (OMIM252600) has been shown to be caused by a reduced level of uridine diphosphate (UDP)-N-acetylglucosamine-1-phosphotransferase enzyme (EC 2.7.8.17) activity. This disorder is caused by mutations in the GNPTAB gene and is inherited in an autosomal recessive manner. Trimethylaminuria (OMIM 602079), fish-odor syndrome, is caused by homozygous or compound heterozygous mutation in the gene encoding flavin-containing monooxygenase-3 (FMO3) on chromosome 1q24. Here we report a 4.5-year-old boy with coexisting of both mucolipidosis type III and trimethylaminuria. He is suffering from a, coarse face, corneal opacity, hearing loss, short stature, hirsutism, umbilical and inguinal hernias, clue hand, developmental delay, and an offensive decaying fishy odor of sweat, breath, and urine since his infancy. Other findings include dysostosis multiplex in skeletal survey, significant increases of multiple lysosomal enzymes’ activities in plasma, and not detectable GAG but huge an amount of TMA in urine. Whole exome sequencing in this patient revealed one novel mutation in the GNPTAB gene and three compound heterozygote mutations in the FMO3. We confirmed these findings by his parents’ and Sanger gene sequencing analysis. Coexistent different inborn errors of metabolism in a patient make the clinical diagnosis and management of the diseases complicated.
614 - Early ERT for MPS IV A (Morquio A) in Under 5-Year-Old Pediatric Patient: 3 Years Follow-Up
Hernan Amartino1, Magdalena Grassi1, Alejandrina Real1, Francisca Masllorens1, Nestor Panattieri1, and Paula Rozenfeld2
1Hospital Austral, Buenos Aires, Argentina
2Universidad Nacional de La Plata, La Plata, Argentina
615 - Oxidative Biomarkers in Morquio A Patients
Bruna Donida1, Desirèe Marchetti1, Carlos Eduardo Diaz Jacques1, Graziela Ribas1, Marion Deon1, Paula Manini2, Helen da Rosa1, Dinara Moura2, Jenifer Saffi2, Roberto Giugliani1, and Carmen Regla Vargas1
1UFRGS, Porto Alegre, RS, Brazil
2UFCSPA, Porto Alegre, RS, Brazil
Morquio A disease is an autosomal recessive inborn error of glycosaminoglycan catabolism due to a defect in N-acetylgalactosamine-6-sulfatase enzyme. This enzyme deficiency is responsible for keratan sulfate and chondroitin 6-sulfate accumulation mainly in the cartilage, cornea and heart valves of Morquio A patients, as well as in blood and urine. As the pathophysiology of this LSD is not completely understood, the aim of this study was to investigate oxidative stress parameters in Morquio A patients at diagnosis. It was studied 15 untreated Morquio A patients, compared with healthy individuals. Damage to lipids was evaluated by urinary 15-F2t-isoprostane levels. To determine oxidative damage to proteins, plasmatic concentration of sulfhydryl groups and urinary di-tyrosine levels were measured. Basal DNA damage was investigated by comet assay and we assessed DNA repair using endonuclease III enzyme which recognizes oxidized pyrimidines bases and converts them into breaks reflected in comet tail. We also determined the urinary 8-hydroxy-2’-deoxyguanosine (8-OHdG) levels, a product of DNA oxidative damage. Reduced glutathione (GSH) levels, the main non-enzymatic intracellular antioxidant, were measured in erythrocytes, as well as the activity of antioxidant enzymes: superoxide dismutase (SOD), glutathione peroxidase (GPx) and glutatione reductase (GR). Finally, urinary keratan sulfate was measured by a LC/MS/MS technique. The affected individuals presented higher lipid peroxidation, and no protein damage. Furthermore, Morquio A patients showed DNA oxidative damage in both pyrimidines and purines bases, being the DNA damage positively correlated with lipid peroxidation. In relation to antioxidant defenses, affected patients presented higher levels of GSH and increased activity of GPx (showing a possible response to oxidative injury), while SOD and GR activities were similar to controls. The urinary keratan sulfate levels were greatly increased in Morquio A patients, and it is important to emphasize that differently of blood samples, urinary KS levels remained high in Morquio A patients even after 20 years of age. Considering the expose, our findings indicate that Morquio A patients at diagnosis present redox imbalance and oxidative damage to lipids and DNA, reinforcing the idea about the importance of antioxidant therapy as an adjuvant treatment in this disorder.
616 - Fabry Disease (FD) Screening Among Females With Kidney Disorders Suggests Absence of the Common Asian Late-Onset or Cardiac GLA Variant c.640-801GA (rs199473684) in the Mexican Population
Miguel Angel Alcantara-Ortigoza and Ariadna Gonzalez-Del Angel
Dna-Gen Sc, Centro de Alta Especialidad En Genética Humana, Mexico City, Mexico
617 - Morphology of Sinus of Valsalva in Patients With Mucopolysaccharidosis
Assel Tulebayeva1, Maira Sharipova2, and Aigerim Mullen1
1Asfendiyarov Kazakh National Medical University, Almaty, Casaquistao
2Scientific Center of Pediatrics and Pediatric Surgery, Almaty, Casaquistao
Background: In patients with mucopolysaccharidosis (MPS) the cardiovascular system is frequently impaired. In clinical studies, aortopathy is common (up to 35%), and is a leading cause of aortic aneurysm and dissection with a high risk of mortality. Objective: To study the morphological features of aortic root anatomy in children with MPS. Materials and methods: 32 children and young adults with MPS (8 with MPS type I, 14 with MPS type II, 4 with MPS type IVA and 6 with MPS type VI). Transthoracic echocardiography was used to assess proximal aortic morphology and function in accordance with the EACVI and ASE standards. Measurements were corrected for BSA calculated using the DuBois formula. Results: The mean size of the aortic root was 16.7 ± 6.4 mm. Only 2 patients, both with MPS II, had evidence of aortopathy. Patient M., 4 years old, height 87 cm, weight 14 kg, BSA = 0.59 m2, the size of the atrioventricular valve is reduced (z-score-1.3). Signs of left ventricle (LV) dilatation (EDI 90 mL/m2). Patient R, 27 years old, height 147 cm, weight 68 kg, BSA = 1.15m2, normal dimensions of the LV cavity (EDI 61.9 mL/m2). In both cases, aortic valves dilatation is significant (z-score 3.0 and 3.6, respectively), especially the sinus of Valsalva (z-score 3.5 and 4.3, respectively). Moreover, the patient M. had an aneurysm of the right coronary sinus. Additionally, the valves of the aortic valve in both children were slightly thickened and there was a failure of the valve function with mild regurgitation (PHT 720 ms and 460 ms, respectively). Hypertrophy of all LV walls was detected only in patient M, the relative thickness 0.46 cm, the LV mass index 173.2 g/m2. While the patient R. had isolated hypertrophy of the posterior wall of the LV. The function of the LV was normal in both patients, with cardiac index 4.7 L/min/m2 and 4.3 L/min/m2 respectively, without calculating the error for aortic insufficiency. Conclusion: Thus, among observed children with MPS in Republic of Kazakhstan aortic root impairment was found only in 2 patients with MPS type II, that is 6,25% of all observed children. It is mandatory to follow up morphology of aortic root in children with dilated sinus of Valsalva.
618 - Molecular Analysis of MPS VI Patients in Brazil
Rowena Couto1, Aline Bochernitsan1, Ana Carolina Brusius-Facchin1, Fernanda Bender1, Fabiana Costa-Motta2, Roberto Giugliani1, and Sandra Leistner-Segal1
1Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
2Universidade Católica de Pelotas, Porto Alegre, RS, Brazil
Mucopolysaccharidosis type VI is a lysosomal autosomal recessive disorder due to ARSB gene mutations which leads to impairment of N-acetylgalactosamine-4-sulfatase(ARSB)enzyme causing a broad spectrum of clinical manifestations. The MPS VI world estimated incidence varies between 1:248 000 and 1:300 000 newborns depending on the region studied. So far, around 200 different mutations in the ARSB gene have been described worldwide. The aim of this study was to characterize the genotype and calculate the frequency of mutations in MPS VI Brazilian patients. The study was conducted at Medical Genetic Service of Hospital de Clínicas de Porto Alegre using PCR followed by Sanger sequencing of the 8 exons and intron boundaries comprising the ARSB gene. The analyses of 116 patients (232 alleles) resulted in 36 different mutations: 21 already described in literature (12 missense, 3 nonsense, 4 deletions, 2 splicing and 1 insertion) and 13 new (8 missense, 1 nonsense, 2 deletions and 2 insertions). The most frequent mutation was c.1143-1G>C in intron 5 with 19,39% (45 alleles), followed by p.Leu72Arg in exon 1 with 16,37% (38 alleles) and c.1143-8G>C also in intron 5 with 13,36% (31 alleles). Exon 1 presented the highest number of detected mutations (n = 14). Six different polymorphisms (SNPs) were found in exons 4,5 and 6 and intron 5, 73% of patients have at least 1 of the 6 SNPs, being the most frequent IVS5-27A>C, in intron 5, present in 40% of patients, from which 54% were homozygous and 46% were heterozygous. Most of the patients included in this study originated from the Northeast (48%) and Southeast (36%), which is in agreement with previous studies showing, that the majority of medical genetic services are located in Southeast and South regions, making it difficult to access for a huge parcel of the Brazilian population. The lack of genetic services, cannot exclude the possibility of the occurrence of patients with genetic diseases, including MPS VI, in those regions. In addition, the large number of patients in the Northeast region is due to the presence of the founder effect of the p.His178Leu mutation in the county of Monte Santo, located in the countryside of Bahia. The observed results throughout the years confirm the broad genetic heterogeneity among MPS VI Brazilian patients. This study will contribute to estimate the real prevalence of MPS VI mutations which is important for epidemiological studies and genetic counseling.
619 - Analysis of Neu1 Regulation by microRNAs From miR-17 Family Differentially Expressed in the Cerebellum of Mucopolysaccharidosis Type I Mice
Vanessa Gonçalves Pereira, Matheus Trovão de Queiroz, Beatriz Santos Oliveira, and Vânia D’Almeida
Universidade Federal de São Paulo, São Paulo, SP, Brazil
In a previous study from our group, three microRNAs (miRNAs) from miR-17 family (miR-20b-3p; miR-20b-5p and miR-106b-5p) were found to be differentially expressed in the cerebellum of mucopolysaccharidosis type I (MPS I) mice, along with a reduction in Neu1 expression. Since those miRNAs are predicted to bind to Neu1, the aim of this study was to analyze the direct binding of miRNAs from miR-17 family to the 3’ UTR of Neu1, which could explain the reduction of Neu1 expression observed in the MPS I mouse model. This binding analysis was performed through luciferase assays. Neu1 3’ UTR was inserted in the cloning site downstream of the luciferase gene in a pMIR-REPORT™ miRNA Expression Reporter, generating pMIR-Neu1-3’UTR plasmids which were transfected to COS-7 cells. MiR-20b-3p, miR-20b-5p and miR-106b-5p mimics were separately transfected to those cells, to evaluate their possible effect on Neu1 expression. Three different miRNA concentrations were tested and the effect of a miRNA scramble transfection was also evaluated. Experimental conditions were analyzed in triplicates and results were confirmed through three independent experiments. No statistically significant differences through Kruskal-Wallis test were observed in luciferase luminescence in the presence of neither miRNAs tested, suggesting that miR-20b-3p, miR-20b-5p and miR-106b-5p do not regulate Neu1 expression by direct binding to its 3’-UTR region. However, these results do not exclude the hypothesis of Neu1 regulation by these miRNAs since they may also act through different mechanisms, including by interaction with other miRNAs and gene networks.
620 - Management Experience of a Cohort of Patients With Mucopolysaccharidosis Type IV A in the Western Center Region of Colombia
Gloria Liliana Porras Hurtado1, Carlos Andres Zapata Chica2, Diana Milena Belalcazar Cifuentes3, and Harry Pachajoa4
1Comfamiliar Risaralda, Pereira, Colombia
2Clinica Comfamiliar Risaralda, Pereira, Colombia
3Metabolic Therapies, Pereira, Colombia
4Icesi, Cali, Colombia
621 - Genetic Diagnosis of Mucopolysaccharidosis in Cuban Patients Through Next Generation Sequencing
Tatiana Acosta1, Rosa Navarrete2, Magdalena Ugarte2, Celia Pérez-Cerdá2, and Belen Pérez2
1Centro Nacional de Genetica Medica de Cuba, La Habana, La Habana, Cuba
2Centro de Diagnóstico de Enfermedades Molecualres, Universidad Autonoma de Madrid, Ciberer, Madrid, Spain
622 - Mucopolysaccharidosis Type I, Scheie Type: Trigger Finger can be a Diagnostic Clue!
Diana Salazar Bermeo1, Rachel Sayuri Honjo1, Sofía Ortiz Saladaña1, Cristina Núñez Vaca1, Santiago Estrella Benavides1, Gustavo Marquezani Spolador1, Jose da Silva Franco1, Juliana Monteiro Dias2, Guilherme Lopes Yamamoto1, Débora Romeo Bertola1, and Chong Ae Kim1
1Genetics Unit of Instituto da Criança do Hospital das Clínicas da Universidade de São Paulo, São Paulo, SP, Brazil
2Pediatrics Department of Instituto da Criança do Hospital das Clínicas da Universidade de São Paulo, São Paulo, SP, Brazil
The Mucopolysaccharidosis I (MPS I) is a lysosomal disorder caused by deficiency of the enzyme alpha-L-iduronidase required for the degradation of glycosaminoglycans (GAGs). MPS I is inherited as an autosomal recessive condition, and it has been divided into three syndromes—Hurler (severe form), Hurler–Scheie (intermediate), and Scheie (milder form). Typical symptoms include corneal clouding, organomegaly, cardiac valve abnormalities, joint contractures, and dysostosis multiplex. Treatment includes enzyme replacement therapy (ERT), hematopoietic stem cell transplantation and symptom-based and palliative care.
623 - Neonatal Form With Severe Cardiac Manifestation in an Infant With Rapidly Progressing Phenotype of Mucopolysaccharidosis Type VI
Cristina Núñez Vaca1, Sofía Ortiz Saldaña2, Diana Salazar Bermeo2, Santiago Estrella Benavides2, Gustavo Marquezani Spolador2, José Ricardo Magliocco Ceroni2, Debora Romeo Bertola2, Guilherme Yamamoto2, Rachel Sayuri Honjo2, Chong Ae Kim2, Diogo Cordeiro de Queiroz Soares2, Marcelo Jatene Biscegli3, Nana Miura Ikari3, Vera Lúcia Jornada Krebs4, Gabriela Nunes Leal5, Ana Maria Martins6, and Deipara Monteiro Abellan7
1Genetics Unit Instituto da Crianca, Hospital das Clinicas da Faculdade da Universidade de São Paulo, Sao Paulo, SP, Brazil
2Genetics Unit Instituto da Crianca, Hospital das Clinicas da Faculdade da Universidade de São Paulo, São Paulo, SP, Brazil
3Unidade de Cardiopatia Congénita Incor-Hcfmusp, São Paulo, SP, Brazil
4Unidade de Neonatologia Icr –Hcfmusp, São Paulo, SP, Brazil
5Serviço de Ecocardiografia Icr-Hcfmusp, São Paulo, SP, Brazil
6Departamento de Pediatria e Centro de Referência Em Erros Inatos do Metabolismo-Unifesp, São Paulo, SP, Brazil
7Unidade de Cardiologia Pediátrica Icr-Hcfmusp, São Paulo, SP, Brazil
The Mucopolysaccharidosis type VI (MPS VI), also known as Maroteaux-Lamy Syndrome, is an autosomal recessive lysosomal disorder caused by the deficiency of the enzyme N-acetylgalactosamine 4-sulfatase. It is described a phenotypic spectrum ranging from mild to severe. Here we report an MPS VI patient whose manifestations started in the prenatal period, rapidly evolving valvular insufficiency with congestive heart failure before one year, which ended up requiring surgical repair.
624 - The Family Quality of Life: A Fundamental Element for the Care of People With Morquio Syndrome
Diana Marcela Ortiz Quiroga1, Yoseth Ariza-Araújo1, and Harry Pachajoa2
1Universidad Icesi, Cali, Colombia
2Universidad Icesi Fundación Clínica Valle Del Lili, Cali, Colombia
625 - School Inclusion and Morquio Syndrome IVA: A Case Study in Two Educational Institutions in Cali, Colombia
Diana Marcela Ortiz Quiroga1, Yoseth Ariza-Araújo1, and Harry Pachajoa2
1Universidad Icesi, Cali, Colombia
2Universidad Icesi Fundación Clínica Valle Del Lili, Cali, Colombia
626 - Mutational Profile of Mucopolysaccharidosis Type I Patients Worldwide
Edina Poletto, Gabriela Pasqualim, Ursula Matte, and Guilherme Baldo
UFRGS, Porto Alegre, RS, Brazil
Mucopolysaccharidosis type I (MPS I) is a rare disorder caused by mutations in the α-L-iduronidase (IDUA) gene. More than 200 pathogenic mutations have been described so far, but their frequencies were not yet analyzed in a worldwide scale. In this study, we analyzed the mutational profile of MPS I patients from different regions of the globe in order to identify the differences between populations. Data were collected from published papers and inclusion criteria used were: information about the country of origin of patients and the absolute number of alleles in the study. Thirty-five papers were selected and used in this analysis. We also interrogated for the most common mutation from each country in Genome Aggregation Database (gnomAD) to evaluate its allelic frequency in the general population. The most common mutation observed among patients was p.Trp402*, being the major allele in Spain, Colombia, Germany, North America, United Kingdom, the Netherlands, Brazil, Australia, Czech Republic, and Slovakia, with frequencies up to 63%. The second most frequent mutation is p.Gln70*, present mainly in the North and East of Europe, in countries as Norway (50%), Russia, Poland, and Austria, ranging from 30% to 50% of alleles. North African countries Morocco, Algeria, and Tunisia have p.Pro533Arg as the most frequent mutation, corresponding to 92%, 81%, and 54% of alleles, respectively. This missense mutation is also present in other Mediterranean countries, such as Turkey, Spain and Italy—mainly in the Sicily region (42%)—and Latin America (Mexico and Brazil), though it is very rare in North Europe, North America, and Australia. Mutations frequently observed in East Asians were not found in Western populations, as c.1190-1G>A, p.Ala79Val, p.Leu346Arg and c.613_617dupTGCTC. Conversely, the mutations p.Trp402* and p.Pro533Arg were not found in patients from East Asia. In gnomAD, allelic frequency among individuals without the disease mirrors the data found in patients. For example, the p.Trp402* allele was observed in Europeans (0.0014) and Latinos (0.0004), but it was not present in Asians or Africans. In conclusion, the most common IDUA mutations in MPS I patients are p.Trp402*, p.Gln70* and p.Pro533Arg, but each country has its own mutational profile. The knowledge of the genetic background of MPS I for each population is essential for developing new therapies that depend on the genotype, as well as provide fast diagnosis and improve the management of patients.
627 - Clinical and Molecular Diagnosis in a Patient With Mucopolysaccharidosis Type IIIC
William Márquez1,2, Carlos Martín Restrepo3, Carlos Garzón4, and Orietta Ivonne Beltrán4
1Enfermedades Metabólicas Fundación HOMI Hospital de la Misericordia, Bogotá, Colombia
2Facultad de Medicina, Universidad Nacional de Colombia, Bogotá, Colombia
3Facultad de Medicina, Universidad del Rosario, Bogotá, Colombia
4Facultad de Medicina, Universidad Militar Nueva Granada, Bogotá, Colombia
628 - Characteristics of Patients With Mucopolysaccharidosis Type II (MPS II) Diagnosed Aged ≥ 5 Years: Data From the Hunter Outcome Survey (HOS)
Paul Harmatz1, Shuan-Pei Lin2, Joseph Muenzer3, Roberto Giugliani4, Nathalie Guffon5, Virginie Jego6, and Barbara Burton7
1Ucsf Benioff Children's Hospital Oakland, Oakland, CA, USA
2Department of Pediatrics, Mackay Memorial Hospital, Taipei, Taiwan
3Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
4Medical Genetics Service/Hcpa, Department of Genetics/Ufrgs And Inagemp, Porto Alegre, RS, Brazil
5Centre de Référence Des Maladies Héréditaires Du Métabolisme, Hôpital Femme Mère Enfants, Bron, France
6Cytel, Inc., Geneva, Switzerland
7Birth Defects and Metabolism, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern Univ, Chicago, IL, USA
Individuals with the severe form of mucopolysaccharidosis type II (MPS II; Hunter syndrome) are rarely diagnosed before 1–2 years of age, with patients with the attenuated form typically diagnosed later. Using data from the HOS global observational registry (Shire, Lexington, MA, USA), clinical characteristics and surgical history of prospective patients aged ≥ 5 years at diagnosis (‘late-diagnosis’) were compared with those aged < 5 years (‘early-diagnosis’). As of January 2016, 204/947 patients were aged ≥ 5 years at diagnosis and 609/947 < 5 years (median ages [P10; P90]: 6.6 [5.0; 15.3] and 2.7 [0.7; 4.1] years, respectively). Median ages at symptom onset were 3.0 (0.5; 7.0) and 1.3 (0.3; 3.3) years. Joint stiffness, hernia and facial features consistent with MPS II were common in both groups (189/200 [95%] vs 537/602 [89%]; 174/198 [88%] vs 475/599 [79%]; 189/200 [95%] vs 563/602 [94%]). However, cognitive impairment and behavioral problems were less common in the late-diagnosis than the early-diagnosis group (81/196 [41%] vs 398/597 [67%]; 73/196 [37%] vs 375/598 [63%]). Median numbers of surgeries per patient were similar in both groups (4 [1; 9] and 5 [1; 10]), but first surgery occurred later in the late-diagnosis than the early-diagnosis group (4.0 [0.2; 16.8] vs 2.3 [0.2; 7.6] years). Hernia repair, carpal tunnel decompression and cervical decompression were more common in the late-diagnosis (n = 204) than the early-diagnosis group (n = 609; 58% vs 48%; 36% vs 26%; 5% vs 2%); conversely, ear tube insertions and adenoidectomies were less common in the late-diagnosis than the early-diagnosis group (46% vs 55%; 42% vs 56%). 14% (28/204) of patients in the late-diagnosis group and 18% (111/609) in the early-diagnosis group had died. Patients diagnosed later in life may have different clinical characteristics than those diagnosed earlier, although with significant morbidity. Further analysis is required to delineate these differences and explore whether longer follow-up time is a factor. Previously presented at WORLDSymposium 2017.
629 - A Novel Mutation (Met1Ile) of a Cuban Patient in the NAGLU Gene With Mucopolysaccharidosis IIIB
Laritza Martínez-Rey1, Tatiana Acosta Sánchez1, Norma de León Ojeda2, Alina García García2, Misleidy Miranda1, Lilia C Marín Padrón1, Iovana Fuentes1, Alexis Alles1, Deynis Carmenate1, Celia Pérez-Cerdá3, Belen Pérez3, and Héctor Vera Cuesta4
1National Center of Medical Genetics, La Habana, Cuba
2William Soler Hospital, La Habana, Cuba
3Centro de Diagnóstico de Enfermedades Moleculares, Madrid, Spain
4Centro Internacional de Restauración Neurológica, La Habana, Cuba
Mucopolysaccharidosis type III (MPS III), also known as Sanfilippo syndrome, is an autosomal recessive lysosomal storage disorder characterized by the accumulation of heparan sulfate. These disorders are classified in four types (A-D). MPS IIIB is caused by mutations in the NAGLU gene. The aim of this study is to describe the clinical, biochemical and molecular findings of a patient with MPS IIIB. The diagnosis was performed by clinical findings suggestive of MPS, qualitative chemical tests in urine of the first urination and Thin Layer Chromatography (TLC) for MPS in 24-hour urine. We quantified the enzymatic activity of N-α-acetylglucosaminidase (NAGLU). The pathogenic variants were identified by mutation analysis. The patient studied was a 4-year-old boy, with a prenatal history of small stomach and oligoamnium in the second and third trimesters of gestation, respectively. He presented with weight and normal height, discrete facial dysmorphia and recurrent respiratory infections from 4 months of age, accompanied by severe episodes of sleep apnea requiring adenotonsillectomy at 2 years. He had hyperactive behavior with signs of aggressiveness and bruxism, associated with bilateral hearing impairment. In the qualitative tests, we detected an increment of GAG in urine. TLC showed urinary heparan sulfate excretion. NAGLU enzyme activity was deficient in leukocytes. In the molecular study of the NAGLU gene we detected 2 mutations: 3G>A (associated with severe phenotypes) and Met1Ile (allelic variant). The Met1Ile mutation was a novel finding. The carrier study in the parents suggested the parental origin of each variant found. The clinical manifestations, the heparan excretion, the decrease in NAGLU activity allowed the diagnosis of a Sanfilippo syndrome B type in this patient. Besides, the molecular study confirmed the presence of a novel mutation associated with this disorder.
630 - A Novel Mutation (c.852-2A>C) of a Cuban Patient in the NAGLU Gene With Mucopolysaccharidosis IIIC
Laritza Martínez-Rey1, Tatiana Acosta Sánchez1, Alina García García2, Lilia C Marín Padrón1, Misleidy Miranda1, Iovana Fuentes1, Alexis Alles1, Deynis Carmenate1, Celia Pérez-Cerdá3, and Belen Pérez3
1National Center of Medical Genetics, La Habana, Cuba
2William Soler Hospital, La Habana, Cuba
3Centro de Diagnóstico de Enfermedades Moleculares, Madrid, Spain
Mucopolysaccharidosis type III (MPS III), also known as Sanfilippo syndrome, is an autosomal recessive lysosomal storage disorder characterized by the accumulation of heparan sulfate. These disorders are classified in four types (A-D). MPS IIIC is caused by mutations in the HGSNAT gene. The aim of this study is to describe the clinical, biochemical and molecular findings of a patient with MPSIIIC. The diagnosis was performed by clinical findings suggestive of MPS, qualitative chemical tests in urine of the first urination and Thin Layer Chromatography (TLC) for MPS in 24-hour urine. We quantified the enzymatic activity of Heparan-α-glucosaminido-N-acetyltransferase (HGSNAT). The pathogenic variants were identified by mutation analysis. We studied a 7-year-old patient with a history of multiple admissions for respiratory infections and surgeries of inguinal-scrotal hernia and adenoiditis from the first year of age. He had attention and hyperactivity disorder with rapid evolution to a significant deterioration of their behavior with implications in family management, educational and social insertion. This child has had focal convulsive seizures since the age of 6, associated with bilateral hearing impairment. We detected an incremented GAG excretion in urine by qualitative chemical tests. TLC showed urinary heparan sulfate excretion. HGSNAT enzymatic activity was deficient. In the molecular study, we confirmed two mutations: c.493 + 1G> A (previously described) and c.852-2A>C (allelic variant). The last one is a novel mutation and severe variant. The carrier study in the mother suggested the parental origin of each variant found. The neurological and psychiatric manifestations, the heparan excretion and the decrease in HGSNAT activity allowed the diagnosis of Sanfilippo syndrome C type in this patient. Besides, the molecular study confirmed the presence of a novel mutation associated with this disorder.
631 - Profile of MPS IVA Patient Sample Followed at the Medical Genetics Service of Hospital de Clínicas de Porto Alegre, Brazil
Luciana Giugliani, Karina Carvalho Donis, Fabiano de Oliveira Poswar, Amanda Teixeira da Rosa, Ana Carolina Brusius-Facchin, Maira Burin, Roberto Giugliani, and Carolina Souza
Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
632 - Clinical, Medical, and Social Aspects of a Brazilian Series of 5 MPS I-Scheie Patients
Karina Carvalho Donis, Fabiano de Oliveira Poswar, Carolina Souza, and Roberto Giugliani
Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
Mucopolysaccharidosis I (MPS I) is a rare inherited, autosomal recessive disorder, caused by deficiency of the lysosomal enzyme, α-iduronidase. MPS I has been classified into a severe (Hurler syndrome) and attenuated types (Hurler-Scheie and Scheie). We are describing the clinical aspects of five MPS I-Scheie female patients followed at the Medical Genetic Service of Hospital de Clínicas de Porto Alegre, Brazil. All patients were diagnosed by this service through specific biochemical tests (high levels of urinary glycosaminoglycans and deficiency of α-iduronidase activity) and molecular analysis (two pathogenic variants in separate alleles of the IDUA gene). The mean age at diagnosis was 12 years (from 5 to 20) and currently the average is 32.4 years (29 to 35). The current mean urinary glycosaminoglycan level is 66.4 (RV 13-45 µg/mg creatinine). All patients are under enzyme replacement therapy with 1.2 mg/kg of laronidase every 2 weeks. Three patients have spinal cord compression; one of them performed two decompression surgeries at 16 and 21 years of age. Four had carpal tunnel syndrome, with onset from 15 to 27 years. Valvulopathy (aortic and/or mitral valve stenosis) is present in all patients. One patient presented moderate aortic stenosis and severe mitral stenosis with presence of thrombi in the left atrium at 35 years old. She was submitted to mitral valve replacement, aortic commissurotomy, and removal of thrombus, without complications. Ophthalmological examination showed corneal clouding in all patients. One out of five has also hypermetropia, astigmatism and glaucoma. Another patient went through two cornea transplantations at 13 and 14 years of age, and one patient performed corneal transplantation at 32 years old (at 27 yo she presented retinal detachment and glaucoma). One patient became pregnant at 27 years old, and remained on enzyme replacement therapy during pregnancy, having delivered a normal baby. She presented no signs of spinal cord compression and there was no change in valvulopathy, but as she had worsening of respiratory symptoms a pre-term caesarean section was recommended.
633 - Early Initiation of Elosulfase Alpha is Associated to Better Outcomes in Mucopolysaccharidosis IVA (MPS IVA)
Karina Carvalho Donis, Fabiano de Oliveira Poswar, Ana Carolina Brusius-Facchin, Sandra Leistner-Segal, Maira Burin, Kristiane Michelin, Carolina Souza, and Roberto Giugliani
Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
We report 2 patients with MPS IVA disease from the same family, consanguineous parents, and analyze their differences regarding disease severity considering the different ages at ERT start. Patient 1: male, 8 years old. He started walking at the age of 1 year and 4 months. At 2 years of age, prominent skeletal abnormalities were noticed. He was diagnosed with MPS IVA at the age of 6 years, quantitative GAGs 335 µg/mg (VR 53-115 µg/mg of Cr), GAGs electrophoresis showed keratan sulfate, galactose-6-sulfate sulfatase indetectable and started elosulfase alpha infusions when 8 years old. Molecular exam GALNS gene showed c.Gly301Cys (p.Gly301Cys) in homozygosis. He is currently well, but with prominent skeletal abnormalities and a very short stature (Z-score −6.4). His MRI shows cervical stenosis, without cord compression. Patient 2: a first cousin of patient 1, male, 2 years old. He was diagnosed with MPS IVA at the age of 8 months, Quantitative GAGs 232 µg/mg (VR 133-274 µg/mg of Cr), GAGs electrophoresis showed Keratan Sulfate, Galactose-6-sulfate sulfatase 4.4 nmol/h/protein (VR 58-242 nmoles/h/protein) and started the ERT at 18 months of age. Molecular exam GALNS gene showed c.Gly301Cys (p.Gly301Cys) in homozygosis. His current length Z score is −0.9. Moreover, in spite of having signs of cord compression, he had a marked improvement of his mobility after ERT and physical therapy.
634 - Systemic and Oral Manifestations in Maroteaux-Lamy Syndrome: Case Report
Marcia Ribeiro1, Rafaela Torres1, Andréa Pintor1, Fábio Guedes1, Gustavo Fonseca2, Raquel Couto1, Ana Carolina Esposito1, Nathalia Santos1, Liana Freitas-Fernandes1, Tatiana Fidalgo2, Raquel Silva2, and Ivete Souza1
1Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
2State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
Maroteaux-Lamy syndrome (MPS VI) is a rare metabolic disorder caused by the deficiency of the N-acetylgalactosamine 4-sulfatase enzyme, responsible for the degradation of glycosaminoglycans, resulting in its accumulation within the lysosomes, resulting in multiple systemic and oral changes. The prevalence of this disease is 1.3-4.5: 100 000 live births. The objective of this study was to describe the medical history, the systemic and oral manifestations of a MPS VI male, 8 years old patient (ESB) assisted at the Genetics Clinic of the Department of Pediatrics of the Federal University of Rio de Janeiro (UFRJ). ESB was the first son of a young and no consanguineous couple; GII/PII, normal pregnancy with spontaneous vaginal delivery, at term (38 weeks) with no asphyxia. Birth weight = 4330 g; birth length = 55 cm, large for gestational age. Developmental milestones (months): held his head at 3, sat without support and first word at 9 and walked at 11. At 14 months, he showed umbilical hernia and macrocrania. He was diagnosed with MPS VI at the age of 2 years old, presenting also short stature, dolycocephaly, coarse face, noisy breathing, skeletal deformities (pectus carinatum, thoraco-lumbar kyphosis), hepatomegaly and Mongolian spots on the back. Enzyme Replacement Therapy with galsulfase was initiated at the age of 2 years 10 months. So far, his cognition is normal. He was referred to the Pediatric Dentistry Clinic / UFRJ for dental evaluation. Anamnesis, clinical examination (evaluation of soft tissues, occlusion, periodontal evaluation, and decayed missing filled surfaces/teeth (DMFT/dmft) index) and computed tomography (CT) of the craniofacial region were performed. Several oral alterations were observed: macroglossia, anterior open bite, high dmft (4), and poor periodontal conditions evidenced by high bleeding probing index (41.1%) and dental biofilm index O’Leary (61.7%). The CT revealed condyles with morphological alterations and severe bilateral hypoplasia, absence of the articular fossae and eminences of the temporomandibular joints, bilateral reduction in mandibular body height in the posterior region, mucosal retention cyst in the right lateral wall of the right sinus, anterior open bite, delayed eruption of the first permanent molars and increase of the periocoronary space of the lower first molars and canines suggesting dentigerous cysts. The systemic alterations hamper the dental treatment and the general prognosis of the patient.
635 - Oxidative Stress Assessment by Glutathione Peroxidase Activity and Glutathione Levels in Response to Selenium Supplementation in Patients With Mucopolysaccharidosis I, II and VI
José Silva, Oliveira Araújo1, Renata Oliveira, Bernardes1, Vaneisse Monteiro2, Joyce Umbelino Silva Yamamoto1, Beatriz J., Frangipani1, Vânia D’Almeida1, and Ana Maria Martins1
1Unifesp, São Paulo, SP, Brazil
2Hospital Pequeno Príncipe, Curitiba, PR, Brazil
636 - Subdural Hemorrhages in a Boy With Mucopolysaccharidosis IIIB
Liliya Osipova
Scientific Center of Children’s Health, Moscow, Russia
Subdural hematomas are most common in infants and elderly adults, result from bridging veins’ tears and usually arise as head trauma outcome. The soft consistency of the unmyelinated brain and cerebral atrophy are likely to be a pathophysiological basis of such age predisposition. Subdural hemorrhages, occurring spontaneously or after head trauma, have been described in several neurometabolic diseases with cerebral atrophy and myelination disturbance, viz glutaric aciduria type I, pyruvate carboxylase deficiency, Menkes disease, D-2-hydroxyglutaric aciduria, methylmalonic aciduria, homocystinuria, Hermansky-Pudlac syndrome, infantile neuronal ceroid lipofuscinosis, MPS II and IIIB. There are scant descriptions of impaired hemostasis in MPS I, II presumably due to anticoagulant activities of glycosaminoglycans. An 8-year-old boy was admitted to neurological department for systematic workup. At 2 years 10-months he was diagnosed with MPS IIIB. During last 2 years, his developmental regression progressed, he completely lost his speech, his motor activity decreased significantly, and in recent months he became fatigued and sleepy and started to experience dysphagia. Brain MRI revealed cerebral atrophy, chronic subdural hematoma of right hemisphere, compression of right hemisphere and right lateral ventricle. 3 weeks later the boy presented with a single episode of adverse seizure with tonic posturing of ipsilateral arm, he started to have hemiparetic gait, got drowsy. Brain KT displayed acute hemorrhage in the region of the chronic subdural hematoma. Laboratory studies demonstrated fluctuating thrombocytopenia, impaired platelet aggregation to ADP and arachidonic acid, decreased level of plasma fibrinogen. He was treated with platelet concentrate transfusion, etamsylate, folic acid and closed external drainage of subdural hematoma was performed. Three months after subdural hematoma surgery the boy presented without apparent neurologic regression compared to previous examination, he still had hemiparetic gait, laboratory workup showed thrombocytopenia, elevation of APTT, impaired platelet aggregation to ADP, arachidonic acid, and thrombin. We conclude that regular neurovisualization and coagulation tests should be included in the standard workup for patients with neuronopathic mucopolysaccharidoses, as constellation of abnormal hemostasis and progressive cerebral atrophy may present a risk of intracranial hemorrhage.
637 - Estimating the Epidemiological Profile of Mucopolysaccharidoses (MPS) in the State of Rio Grande do Norte (RN) in the Period From 1995 to 2015
João Ivanildo da Costa Ferreira Neri1, Maria Antonia Ferreira Gomes2, Zêmia Maria Câmara Costa Ferreira2, Francielly Cunha2, Hugo Macedo de Moura2, and Lana Lira Cantidio de Medeiros2
1Specialized Center in Rehabilitation and Habilitation of Rio Grande do Norte (Cri)-Sesap-Rn, Natal, RN, Brazil
2Potiguar University (Unp)-Laureate International Universities, Natal, RN, Brazil
MPS are characterized by the intralysosomic accumulation of glycosaminoglycans (GAGs), secondary to a deficient activity of one of the enzymes involved in the degradation of GAGs, being classified in MPS I, MPS II, MPS III-A, MPS III-B, MPS III C, MPS III-D, MPS IV-A, MPS IV-B, MPS VI, MPS VII, and MPS IX. The worldwide incidence of MPS ranges from 1.9 to 4.5 cases in 100 000 births. In Brazil, the prevalence is still unknown, but, according to a survey by the MPS Brazil Network, it is known that there are about 250 patients with MPS in the whole country. Comparing the epidemiological profile of the MPS in the RN in a period of 20 years in relation to the prevalence in Brazil and in the world, we performed a descriptive study carried out with SESAP/RN from the analysis of medical records of patients attended at the medical genetics outpatient clinic and diagnosed with MPS in the RN from 1995 to 2015. Data regarding the type of disease, sex and City of origin of the affected.
638 - Mucopolysaccharidosis Type IV A in a Patient With Congenital Glaucoma
Ali Dursun1, Berrak Bilginer Gurbuz1, Olcay Tatar2, Serap Sivri1, Turgay Coskun1
1Hacettepe University, Pediatric Metabolism, Ankara, Turkey
2Hacettepe University, Ophthalmology, Ankara, Turkey
The Mucopolysaccharidose (MPS) type 4A (Morquio) is an autosomal recessive inherited lysosomal storage disorder characterized by the accumulation of keratan sulfate and chondroitin-6-sulfate in cornea and bone and associated with N-acetyl galactosamine-6-sulfate sulfatase deficiency. Major clinical findings are short stature, skeletal dysplasia, dental anomalies and corneal clouding. These can also be accompanied by nerve-type hearing loss, heart valve diseases, joint laxity, and cervical myelopathy. This disease can treat with enzyme replacement therapy and gene therapy due to absence of central nervous system involvement. Typical ocular manifestations in many children with MPS type 4A include corneal clouding, retinal degeneration, reduced electroretinogram wave amplitude, optic nerve atrophy, papillary edema, and glaucoma. Herein we described a MPS type 4A patient with bilateral congenital glaucoma.
639 - Computational Analysis of Mouse Brain Interactome for the Lysosomal Enzyme Iduronate-2-Sulfatase
Eliana Benincore-Flórez, Carolina Cardona, Camilo Patarroyo, Luisa Natalia Pimentel Vera, Edwin Alexander Rodríguez, and Carlos Alméciga-Díaz
Instituto de Errores Innatos del Metabolismo, Bogotá, Colombia
Mucopolysaccharidosis type II (MPS II) is a lysosomal storage disease caused by the deficiency of iduronate-2-sulfatase (IDS), which leads to the subsequent storage of undegraded glycosaminoglycans heparan and dermatan sulfate. There is limited information about the IDS interactome in brain or other tissues. In this study, we used bioinformatics tools to study an IDS proteome previously isolated from a whole cellular extract of wild-type mouse brain. The proteome, which comprises 217 proteins, was analyzed with PPI Spider and GENEMANIA, to predict an interaction network and identify potential protein-protein interactions. The networks were visualized by Cytoscape. The analysis of networks allowed to predict 32 proteins with potential protein-protein (physical) interactions with IDS. This protein dataset was investigated regarding their functional categories, biological pathways and functional localization by using PANTHER and DAVID database. Proteins were divided into the following groups based on their functional annotations: 1) Formation and trafficking of vesicles, 2) Scaffold proteins, 3) Proteins related to ATPase activity, 4) Signaling cascades, 5) Transcriptional factors, 6) Cell adhesion, 7) Intermediate metabolism, 8) Neurofilaments and cytoskeleton, and 9) Anchorage proteins and receptors. According to this information, we selected 10 proteins to validate their physical interaction with IDS: SYT1, ALDOA, 1433Z, 1433G, CAMKV, PRDX2, HSP7C, ALDOC, LSAMP, and EAA1. These results represent valuable information in the characterization of protein-protein interactions for IDS in brain, which will allow us to increase our knowledge about the role of IDS under physiological conditions, as well as the implications of its deficiency in MPS II patients.
640 - Macular Edema Reduction After Long Term Enzyme Replacement Therapy in Mucopolysaccharidosis Type II (Hunter Syndrome): A Case Report
Juan Pablo Salica and Hernan Amartino
Hospital Austral, Buenos Aires, Argentina
Ocular abnormalities in Hunter syndrome include exophthalmos, disk swelling, optic atrophy, and retinopathy. Accumulation of GAGs in retinal tissue induced retinal degeneration and pigmentary retinopathy. Macular edema was occasionally described in MPSII. Spectral Domain Optical Coherence Tomography (SD-OCT) is a useful tool for detecting retinal pathology, particularly macular changes.
641 - The Limitations to Enzyme Replacement Therapy in a 14-Year-Old Boy With MPS II Who is Morbidly Obese
Maria Normoyle
Royal Children’s Hospital, Melbourne, Australia
Mucopolysaccharidosis type II (MPS II; Hunter Disease) is a rare inborn error of metabolism resulting from a deficiency in the Iduronate 2-sulfatase enzyme. MPS II affects numerous systems including the central and peripheral nervous systems and the cardiovascular, gastrointestinal, respiratory, and musculo-skeletal systems. In Australia, ERT for MPS II is funded by the Federal Government through the Life Saving Drug Program (LSDP). A 14-year-old boy from rural Victoria was diagnosed with MPS II at 7 years of age but started ERT only at 12 years of age due to the family’s reluctance to access treatment. Currently the patient is attending the hospital for weekly ERT treatment and the many sub specialty appointments required for the provision of continued ERT treatment, as per the LSDP. Despite the long distance between home and the hospital and challenging social issues, there has been very good compliance with attendance at all required medical appointments (weekly ERT and 48 sub-specialty face-to-face encounters between April 2016 and April 2017). Like many patients with MPS II, our patient requires many surgical procedures such as C-spine stabilization, Tonsillectomy and Adenoidectomy, carpel tunnel release surgery and insertion of a permanent central venous access device (CVAD) for the provision of ERT. This patient is morbidly obese (currently, at 14 years of age: weight 107 kg; height 143.5 cm, body mass index 49.87 kg/m2). The patient is becoming increasingly difficult to cannulate and without a long-term CVAD line for the intra-venous infusions to be administered through, there may come a time when it will be impossible to administer the ERT. However, his obesity poses an additional high risk for anesthesia. It was made clear by the anesthetic team that before any intervention, he must lose weight. Weight management is multifactorial. It requires the child and family to comprehend the risk of obesity. Consideration must be given to the family’s financial abilities and social support. Current strategies to control and manage his weight, including dietetic advice and monitoring have been unsuccessful due to poor compliance. The lack of local professional psychological and family support and the need to manage his weight through long distance consultation adds to the difficulties. The possibility of reaching an end-point with no ability to provide on-going ERT is a difficult issue to address with a patient and family.
642 - Clinical Trial of Intracranioventricular Enzyme Replacement Therapy for Hunter Syndrome
Torayuki Okuyama1, Motomichi Kosuga2, Takashi Hamazaki3, Haruo Shintaku4, and Seo Jyu-Hyon2
1National Center for Child health And Development, Tokyo, Japan
2National Center for Child Health and Development, Tokyo, Japan
3Osaki City University, Osaka, Japan
4Osaka City University, Osaka, Japan
To evaluate efficacy on neurocognitive function of patients with mucopolysaccharidosis type II (MPSII), we have started a 52-week, multicenter, single arm, open-label phase I/II clinical trial. The participants first receive implantation of CSF Reservoir System. Idursulfase beta (supplied by Green Corss) is injected into cerebroventricular space via the device monthly for 48 weeks. Weekly i.v. idursulfase treatment is continued throughout this study without overlapping 24 hr period before or after ICV injection. The primary endpoint is to detect declining from base line heparan sulfate in cerebrospinal fluid at 52 weeks. The secondary endpoint is to assess change of developmental age after 12 months of treatment at visit week 52, as obtained by Kyoto Scale of Psychological Development and other scales if available. Six patients with genetically and enzymatically diagnosed on MPSII have been enrolled in this study. This study is going without any serious adverse reactions. We observe significant decrease of heparan sulfate concentration in cerebrospinal fluid in all six patents.
643 - Mucopolysaccharidosis—Is There a Link Between Disease Severity and Nutritional Status? A cross-sectional Portuguese study
Ana Faria1, Paula Garcia1, E Rodrigues2, Maria do Carmo Macário1, Esmeralda Martins3, Patricia Janeiro4, and Luisa Diogo1
1Reference Centre of Inherited Metabolic Diseases, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
2Reference Centre of Inherited Metabolic Diseases, Centro Hospitalar São João, Porto, Portugal
3Reference Centre of Inherited Metabolic Diseases, Centro Hospitalar do Porto, Porto, Portugal
4Reference Centre of Inherited Metabolic Diseases Centro Hospitalar de Lisboa Norte, Lisboa, Portugal
644 - Pre-Post Treatment Urinary Glycosylated Lysine in Mucopolysaccharidoses Patients
Nina Patel1, Ivan Doykov1, Simon Heales2, Derek Burke2, Peter Clayton1, Philippa Mills1, Maureen Cleary2, James Davison2, Tenni Rugero3, Kevin Mills1, Paul Gissen1, and Wendy Heywood1
1Ucl Institute of Child Health, London, United Kingdom
2Great Ormond Street Hospital for Children, London, United Kingdom
3University of Pavia, Pavia, Italy
Collagens are subject to post-translational modifications including hydroxylation and subsequent glycosylation of lysines and prolines. We have developed a simple LC-MS/MS method to monitor the modification and hence metabolism of glycosylated collagen in urine. Collagen IV is highly glycosylated and is the main collagen found in basement membranes. Extracellular matrix disruption is known to be an early pathological feature in the mucopolysaccharidoses (MPS). Elevated glycosylated collagen is observed in other bone disorders and free glycosylated lysine is elevated in MPS patient urine.
645 - Quality of Life of a Group of Patients With Mucopolysaccharidosis Type IVA and VI of COLOMBIA and Argentina in Enzyme Replacement Therapy
Gloria Liliana Porras Hurtado1, Analia Cabrera2, Jorge Mario Estrada1, Maximiliano Gatti2, Humberto Fain2, and Alejandro Salazar3
1Comfamiliar Risaralda, Pereira, Colombia
2Hospital de Niños Vilela, Rosario, Argentina
3Clinica Comfamiliar Risaralda, Pereira, Colombia
646 - Use of Methylphenidate for Treatment of Hyperactivity in Children With MPS II (Hunter Syndrome)
Hernan Amartino, Magdalena Grassi, Agustina Donato, and Alba Richaudeau
Hospital Austral, Buenos Aires, Argentina
Hunter syndrome (MPSII) is an X-linked chromosomal storage disorder due to deficiency of the lysosomal enzyme iduronate-2-sulfatase. It is clinically divided into severe or “neuronopathic” form (about 2/3 of cases) and attenuated or “non-neuronopathic” phenotype. Hyperactive behavior is a very common clinical feature in MPSII during childhood. However, literature evidence about treatment with psychoactive agents for hyperactivity in MPSII is lacking. This study evaluates methylphenidate (MPH) safety and efficacy in a cohort of pediatric patients with Hunter syndrome.
647 - A Novel Variant at Exon 9 of Iduronate 2-Sulfatase Gene in an Indonesian Patient With Mucopolysaccharidosis Type II
Yulia Ariani, Rizky Priambodo, Cut Hafifah, and Damayanti Rusli Sjarif
Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
Mucopolysaccharidosis type II or Hunter syndrome is one of the lysosomal storage diseases caused by the absence or malfunctioning of iduronate 2-sulfatase (I2 S) enzyme in the lysosome due to alteration of iduronate 2-sulfatase (IDS) gene. Normally, I2 S enzyme works in the degradation of heparan and dermatan sulfate. An alteration of IDS gene will cause the abnormality of this process and cause the accumulation of both glycosaminoglycans (GAGs) in tissues or organs which will lead to the occurrence of symptoms. This case report aimed to demonstrate our first MPS type II patient which tested for genetic analysis using Sanger sequencing method. A 3-year-old boy, diagnosed as MPS type II based on a very low I2 S enzyme activity. This patient was first brought to Department of Neurology due to speech delay and facial changes since 1.5 years old. There was no motor delay, but mother noticed stiffness of both hands. He is the first child from Indonesia non-consanguineous parents. He was born spontaneously with unremarkable history. He has normal growth and development until 1-year-old. Physical examination showed coarse facies, frontal bossing, enlarged adenoid and joint arthropathy. Supporting examination revealed “bullet shaped” of cervical vertebrae, trivial mitral regurgitation from echocardiography, normal liver size from abdominal ultrasound, narrowing of foramen magnum from brain CT-scan, and severe sinusitis. This patient is our first case that receives genetic testing to find pathogenic variant. Pathogenic variants are frequently reported being located at exon 9, especially in Asian population. Due to limited resources, we first tried to do Sanger sequencing at exon 9. A pair of primers reported in one study from Taiwan are being used to amplify exon 9. Using Sanger sequencing, this exon being sequenced. One single-nucleotide alteration variant in exon 9 was found. This alteration has never been reported elsewhere. This novel variant (c.1506G>C) lead to the alteration of amino acid, from tryptophan to cysteine (p.Trp502Cys). A novel variant (c.1506G>C) is a candidate disease-causing mutation which might affect the normal structure and function the of I2 S enzyme. In silico analysis using bioinformatics approach might help to predict protein structural and function alteration. Sequencing other exons is our next step to be done. Considering the wide variety of mutation in the IDS gene, the need to check the possibility of other variants in other exons is a must.
648 - ZFN-Mediated In Vivo Genome Editing Results in Phenotypic Correction in MPS I and MPS II Mouse Models
Russell Dekelver1, Li Ou2, Kanut Laoharawee2, Susan Tom1, Robert Radeke1, Michelle Rohde1, Scott Sproul1, Michael Przybilla2, Brenda Koniar2, Kelly Podetz-Pedersen2, Renee Cooksley2, Michael Holmes1, R. Scott Mcivor2, Chester B. Whitley2, and Thomas Wechsler1
1Sangamo Therapeutics, Richmond, CA, USA
2University of Minnesota, Minneapolis, MN, USA
Mucopolysaccharidosis (MPS) types I and II result from the deficiency of lysosomal enzymes α-L-iduronidase (IDUA) and iduronate 2-sulfatase (IDS), respectively, and the accumulation of glycosaminoglycans (GAGs) substrates, with severe patient morbidity and shortened lifespan. Although severe MPS I (Hurler syndrome) can be treated by hematopoietic stem cell transplantation, this carries significant morbidity and mortality risks. Additional treatment for MPS I & II consists of enzyme replacement therapy, which slows disease progression but requires lifelong weekly infusions and is a severe hardship on patients. We have developed a ZFN-mediated genome editing strategy to permanently modify patient liver cells through insertion of a corrective hIDUA or hIDS gene at the Albumin locus. Insertion into this locus and co-opting its high-level transcriptional activity potentially provides long-term expression of the corrective transgene in stably modified hepatocytes. This avoids potential issues associated with non-integrating gene therapy approaches; particularly for liver-directed treatment of pediatric disease where significant hepatic cellular division during growth and development create a potential loss of episomal vector genomes. In MPS I and MPS II mouse models, treatment with AAV2/8 vectors comprising the Albumin-targeting ZFNs and the respective corrective human transgene donor, results in supraphysiological hIDUA or hIDS hepatic enzyme levels, secretion of active enzyme into the plasma, and uptake by secondary tissues at levels sufficient for complete clearance of GAG substrate. Histological observations show reduced disease-related cellular vacuolation in the liver and other target tissues. Specific Mass Spec analysis of heparan and dermatan sulfate in the brain demonstrated systemic reduction of GAG accumulation. ZFN+Donor treatment prevented cognitive deficits exhibited in both animal models in the Barnes maze at 4 months post-treatment, where treated and wild-type animals exhibited similar cognitive behavior. Biochemical characterization of expressed hIDS and hIDUA proteins demonstrated the expected glycosylation patterns, and we found mannose-6-phosphate-dependent cellular uptake in vitro. In summary, our results provide proof-of-concept for ZFN-mediated targeting of the Albumin locus in hepatocytes to express therapeutic amounts of hIDUA and hIDS for the treatment of MPS I & II. We currently have open clinical studies for both diseases.
649 - Presenting Signs and Symptoms of MPS: Results of an International Physician Survey
Lorne Clarke1, Carolyn Ellaway2, Helen Foster3, Roberto Giugliani4, Cyril Goizet5, Sarah Goring6, Sara Hawley7, Elaina Jurecki7, Zaeem Khan6, Christina Lampe8, Ken Martin9, Suzanne Mcmullen6, John Mitchell10, Fathima Mubarack7, Joseph Muenzer11, Serap Sivri12, Fiona J. Stewart13, Anna Tylki-Szymanska14, Klane White15, and Frits Wijburg16
1British Columbia Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
2Sydney Children's Hosptital Network, Sydney University, Sydney, Australia
3Great North Children’s Hospital and Newcastle University, Newcastle Upon Tyne, United Kingdom
4Med Genet Serv Hcpa, Dep Genet Ufrgs & Inagemp, Porto Alegre, RS, Brazil
5University Hospital of Bordeaux, Bordeaux University, Bordeaux, France
6Icon Plc, Vancouver, Canada
7Biomarin Pharmaceutical Inc., Novato, CA, USA
8Centre for Rare Diseases, Clinic for Children and Adolescents, Helios Dr. Horst Schmidt Kliniken, Wiesbaden, Germany
9Ucsf Benioff Children’s Hosptital Oakland, Oakland, CA, USA
10Montreal Children’s Hospital, Quebec, Canada
11University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
12Hacettepe University Children’s Hospital, Ankara, Turkey
13Belfast City Hospital, Belfast, United Kingdom
14Children’s Memorial Health Institute, Warsaw, Poland
15Seattle Children’s Hospital, Seattle, WA, USA
16Academic Medical Center, University Hospital of Amsterdam, Amsterdam, the Netherlands
650 - Surgical Procedures in MPS Pediatric Patients
Mireia Del Toro, Jordi Perez, Cesar Garcia-Fontecha, Mario Aguirre, Marc Pellicer, Maria Antonia Poca, Nuria Montferrer, Ana Felipe, and Alfons Macaya
Hospital Universitari Vall D’Hebron, Barcelona, Spain
651 - Pheno-Genotypic Features and Long-Term Enzyme Replacement Treatment Results of 18 Turkish Mucopolysaccharidosis Type II Patients From a Single Center
Deniz Kor1, Berna Seker Yilmaz2, Fatma Derya Bulut2, Sebile Kilavuz2, Selçuk Sizmaz3, Tuğsan Balli4, Hasan Bilen Onan4, Derviş Mansuri5, Muhammed Dağkiran6, and Neslihan Mungan2
1Div Ped Metab Dis, Adana Numune Edu Res Hosp, Adana, Turkey
2Div Ped Metab Dis, Uni Cukurova, Adana, Turkey
3Div Ophthalmol, Uni Cukurova, Adana, Turkey
4Div Radiology, Uni Cukurova, Adana, Turkey
5Div Neurosurgery, Uni Cukurova, Adana, Turkey
6Div Otorhinolaryngology, Uni Cukurova, Adana, Turkey
652 - Recombinant N-Acetylgalactosamine-6-Sulfate Sulfatase (GALNS) Enzyme Produced in Pichia Pastoris: In Vitro and In Vivo characterization
Alexander Rodriguez-López1, Luisa Natalia Pimentel Vera1, Angela Espejo1, Shunji Tomatsu2, and Carlos Alméciga-Díaz1
1Instituto de Errores Innatos Del Metabolismo, Pontificia Universidad Javeriana, Bogota, Colombia
2Nemours/Alfred I. Dupont Hospital for Children, Wilmington, NC, USA
Mucopolysaccharidosis IV A (MPS IVA, Morquio A disease) is a lysosomal storage disease produced by mutations in N-acetylgalactosamine-6-sulfate sulfatase (GALNS) enzyme. Currently, the treatment for MPS IVA disease is based on enzyme replacement therapy (ERT) by using of elosulfase alfa. Although ERT with elosulfase alfa is a therapeutic option for MPS IVA patients, it has limitations including i) a limited effect on skeletal, corneal, and heart valvular issues, ii) a short half-life of the enzyme, iii) immunological issues, and iv) the high cost. Previously, we had reported the production of the recombinant GALNS enzyme in the yeast Pichia pastoris as an alternative for Morquio A ERT. In this study, we present the results of the in-vitro characterization and biodistribution of this recombinant enzyme. The cell up-take was evaluated in HEK293 cells, Morquio A fibroblasts and wild-type mouse chondrocytes. Intracellular traffic was evaluated in HEK293 cells using an AlexaFluor 568 stained enzyme. Reduction of Keratan Sulfate (KS) was evaluated in Morquio A fibroblasts by using HPLC-MS/MS. In-vivo biodistribution was studied in wild-type C57Bl/6 mice using an AlexaFluor 568 stained enzyme. The cell uptake results showed that the internalization process is mediated by both mannose (MR) and mannose-6-phosphate (M6PR) receptors. However, in chondrocytes, this process was mainly mediated by MR than for M6PR. Cell uptake assays using Morquio A fibroblasts, showed that the enzyme was taken up reaching intracellular enzyme activity levels similar to those observed in fibroblast from healthy volunteers; while the intracellular traffic assay, using HEK293 cells, showed that this enzyme was targeted to the lysosome. It is noteworthy that this recombinant GALNS allowed the reduction of KS in Morquio A fibroblasts. For the biodistribution assay in wild-type mice, intravenous doses of 5 mg/kg were administered and tissue samples were taken at 12 and 24 hours. At 12 hours postinjection, it was observed the enzyme was primarily recovered in the liver, spleen, kidney and heart; while at 24 h post-injection the enzyme was only detected in liver and spleen. In conclusion, these results show the ability of the enzyme to reach several tissues and to be up taken by cells through different pathways, which confirm the potential of these enzyme towards the development of a new ERT for Morquio A disease.
653 - Evaluation of Cardiac and Vascular Involvement in Patients With Mucopolysaccharidosis
Ebru Canda1, Melis Kose1, Mehtap Kagnici1, Meral Dondurmaci2, Sema Kalkan Uçar1, Eser Sozmen2, R. Erturk Levent3, and Mahmut Çoker1
1Ege University Faculty of Medicine Pediatric Metabolism and Nutrition, Izmir, Turkey
2Ege University Faculty of Medicine Department of Biochemistry, Izmir, Turkey
3Ege University Faculty of Medicine Pediatric Cardiology, Izmir, Turkey
Cardiovascular involvement is common in patients with Mucopolysaccharidoses (MPS). In this study, we investigated the effects of the markers involved in vascular endothelial injury pathogenesis (transforming growth factor β-TGF-β, interleukin-IL 6, IL 10, high sensitive C reactive protein-hs CRP, vascular endothelial growth factor-VEGF, N-terminal pro- Natriuretic peptide-NT-proBNP) and clinical, laboratory and echocardiographic findings of the patients. The same age and gender were compared with the healthy control group. A total of 37 patients (5 MPS I, 4 MPS II, 2 MPS IIIa, 4 MPS IIIb, 14 MPS IVa, and 8 MPS VI) were included in the study and 32 controls with similar age and sex were included in the study. All of the patients had evidence of dysostosis multiplexes. Corneal clouding was seen in 29 patients. 2 patients were transferred to the cornea. There were 23 patients with organomegaly, and 28 patients with hearing loss. When the groups were compared in terms of NT-proBNP, hsCRP, TGF-β, IL6, IL10 and VEGF levels, there was a statistically significant increase in the patient group (P = .04, P = .022, P = .032, P = .026, P = .037, P = .025, respectively) . The carotid intima media thickness was statistically significantly higher in the patient group (P < .01). Left ventricular diastolic diameter was significantly higher in the patient group (P = 0.09). Intraventricular septum thickness was significantly higher in the patient group (P <0.01). E / A ratio was significantly lower in the patient group (P < .01). Percentage of right ventricular ejection fraction and right ventricular fractional shortening were significantly lower in the patient group (P = .01 and P = .029, respectively). Cardiac involvement in MPS patients is a major cause of mortality and morbidity. It is thought that cytokines, proinflammatory markers are elevated in patients with vasculature damage similar to other lysosomal diseases. There is a need for further studies to determine biomarkers for vascular involvement.
654 - Analysis of the Founder Effect of the Nonsense Variant in the HGSNAT Gene, in the Runta, Boyacá Population
Harvy Velasco1, Leandra Torres1, Yasmin Sanchez2, Sidney Santos3, and Tatiana Vinasco3
1Universidad Nacional de Colombia, Bogotá, Colombia
2Hospital San Rafael de Tunja, Tunja, Colombia
3Universidad Federal de Pará, Belém, PA, Brazil
655 - Prenatal Diagnosis for Lysosomal Disorders: A Reference Center Experience
Maira Burin1, Kristiane Michelin1, Ana Magalhães1, Jurema de Mari1, Fernanda Sebastião1, Rejane Kessler1, Maria Teresa Sanseverino1, Antonio Magalhães1, Ana Carolina Brusius-Facchin1, Franciele Trapp1, Sandra Leistner-Segal1, Ursula Matte2, Ida Vanessa D. Schwartz Schwartz2, Roand berto Giugliani2
1Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
2Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
656 - Correlation of CSF Flow by Using Phase-Contrast MRI With Ventriculomegaly and CSF Opening Pressure in Mucopolysaccharidoses
Amauri Dalla-Corte1, Carolina Souza2, Maurício Anés2, Fabio Maeda3, Leonardo Vedolin4, Monica Ferreira2, Solanger Perrone2, Armelle Lokossou5, Olivier Balédent5, and Roberto Giugliani1
1Universidade do Rio Grande do Sul, Porto Alegre, RS, Brazil
2Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
3Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil
4Dasa, São Paulo, SP, Brazil
5University of Picardie Jules Verne, Amiens, France
657 - Mucopolysaccharidoses Type III: Case Series From Turkey
Fatma Derya Bulut1, Deniz Kor1, Berna Seker Yilmaz1, Sebile Kilavuz1, Mehmet Nuri Özbek2, Süreyya Soyupak1, Elif Erdem1, Tuğsan Balli1, Faruk Incecik1, and Neslihan Mungan1
1Çukurova University, Adana, Turkey
2Diyarbakir Çocuk Hastanesi, Diyarbakir, Turkey
658 - Analysis of Heparan Sulfate and Non-Reducing Ends in Mucopolysaccharidosis Type I
Marzia Pasquali1, Amanda Thomas1, Lis Schwarz2, Carrie Bailey3, Dave Viskochil3, and Patti Dickson4
1 Arup Laboratories, University of Utah Health Sciences Center, Salt Lake City, UT, USA
2Arup Institute for Clinical and Experimental Pathology, Salt Lake City, UT, USA
3University of Utah Health Sciences Center, Salt Lake City, UT, USA
4Los Angeles Biomedical Research Institute at Harbor-Ucla Medical Center, Torrance, CA, USA
Mucopolysaccharidosis type I (MPS-I) is a lysosomal storage disorder caused by deficiency of alpha-L-iduronidase, resulting in impaired degradation of dermatan and heparan sulfate and their accumulation in tissues. Heparan and dermatan sulfate are degraded in lysosomes by specific enzymes through a sequential process starting at the non-reducing end (NRE) of the molecule. The heparan sulfate non-reducing end (NRE) specific for MPS I is a disaccharide composed of iduronic acid and N-sulfoglucosamine referred to as I0S0. In patients with the different forms of MPS I, ranging from the severe neuronopathic Hurler Syndrome to the attenuated Hurler-Scheie and Scheie Syndromes, enzyme replacement therapy (laronidase) and hematopoietic stem cell transplant early in life (only for Hurler syndrome) slow disease progression and improve some clinical symptoms. Here, we evaluate the clinical utility of total heparan sulfate and MPS I specific heparan sulfate NRE using the LC-MS/MS based Sensi-Pro® assay in a cohort of patients with MPS I. At diagnosis, the highest values for the ratio I0S0: HS (>0.06) were seen in patients with Hurler syndrome, while the lowest (0.02) was observed in one patient with Scheie syndrome, the least severe phenotype. Patients with Hurler-Scheie had intermediate values of the ratio (0.02-0.06). The concentration of total GAGs and total heparan sulfate, although elevated in all patients, could not discriminate the three sub-groups. Enzyme replacement therapy (ERT) and/or bone marrow transplant decreased the ratio I0S0: HS and correlated with slowing of symptom progression. Non-compliance with ERT regimen in one Hurler-Scheie patient resulted in increased I0S0: HS ratio. Our preliminary results suggest that the ratio I0S0/total heparan sulfate (I0S0: HS) is a good predictor of disease severity and that disease specific NREs may be used as biochemical markers to monitor treatment compliance and clinical progression in MPS I.
659 - Pentosan Polysulfate for the Mucopolysaccharidosis and Other Lysosomal Storage Diseases
Calogera Simonaro1, Paula Rozenfeld2, and Edward Schuchman1
1Icahn School of Medicine at Mount Sinai, New York, NY, USA
2Iifp (Universidad Nacional de La Plata Y Conicet), La Plata, Argentina
The mucopolysaccharidoses (MPS) comprise a group of 11 lysosomal storage disorders (LSDs) due to deficiencies of enzymes involved in glycosaminoglycan (GAG) metabolism. Our laboratory has specifically focused on understanding the skeletal biology in these diseases, leading to a series of papers documenting the involvement of the toll-like receptor 4 (TLR4) inflammatory pathways. This led to the evaluation of an FDA/EMA-approved drug, pentosan polysulfate (PPS), in two animal models of MPS, rats with MPS VI and dogs with MPS I. Weekly or biweekly subcutaneous injection of PPS into these animals reduced inflammation, improved certain pathological and/or clinical findings, and led to a surprising reduction of GAG storage in tissues and urine. The mechanism(s) responsible for PPS-mediated GAG reduction in MPS are under investigation, but hypotheses include an inhibitory effect on GAG synthesis (i.e., substrate reduction), and/or a stabilizing effect on lysosomal integrity and function. The findings in MPS animals led to two small “proof-of-concept” clinical trials in adult MPS I and MPS II patients, confirming the reduction in inflammation and/or GAG storage. We have also recently completed studies in a mouse model of MPS IIIA, indicating a reduction in systemic and neurological inflammation, and improvement in several other neuropathological findings. Based on these findings we propose that PPS may provide broad benefit across all MPS types, and perhaps other LSDs as well. With regard to this latter point, recent data has shown a reduction of inflammation in cells from patients with Fabry and Gaucher diseases, indicating that the effects of PPS may not be limited to MPS.
660 - A New Recombinant Enzyme for Morquio A Enzyme Replacement Therapy: N-Acetylgalactosamine-6-Sulfate Sulfatase (Galns) Produced in a Glycoengineered Escherichia coli Strain
Luisa Natalia Pimentel Vera1, Edwin Alexander Rodríguez1, Angela Espejo Mojica1, Carolina Cardona Ramírez1, Matthew Delisa2, Oscar F. Sanchez M.3, Shunji Tomatsu4, and Carlos Alméciga-Díaz1
1Pontificia Universidad Javeriana, Bogota, Colombia
2Cornell University, Ithaca, NY, USA
3Purdue University, Indianapolis, IN, USA
4Nemours/Alfred I. Dupont Hospital for Children, Wilmington, NC, USA
Morquio A disease (Mucopolysaccharidosis IV A, MPS IVA) is a lysosomal storage disease (LSD) produced by mutations in the gene encoding for the lysosomal enzyme N-acetylgalactosamine-6-sulfate sulfatase (GALNS, EC 3.1.6.4). The enzyme replacement therapy (ERT) for MPS IVA was recently approved, which is based in the infusion of the recombinant enzyme Elosulfasa Alfa, produced in Chinese Hamster Ovary (CHO) cells. A growing number of studies have shown the possibility to produce active and therapeutic forms of lysosomal proteins in microorganisms. Although Escherichia coli is one of the most used host for the production of recombinant proteins, this expression systems does not perform some the posttranslational modifications observed in mammalian proteins, such as N-glycosylations. In this study, we used a glycoengineered E. coli strain to produce an N-glycosylated recombinant GALNS. The N-glycosylated recombinant GALNS (glycoGALNS) was characterized by its pH stability, kinetic parameters, cell uptake, intracellular traffic, and in vitro reduction of keratan sulfate (KS), and mouse biodistribution. The glycoGALNS showed higher stability at low pH values than the non-glycosylated version of the protein. Furthermore, the addition of N-glycosylations also improved the affinity for the artificial substrate. Cell uptake assays, using Morquio A fibroblasts, showed that the enzyme was taken up reaching intracellular enzyme activity levels similar to those observed in fibroblast from healthy individuals, in a process mediated by mannose receptors. Intracellular traffic assay, using HEK293 cells and an AlexaFluor 568 stained enzyme, showed that this enzyme was targeted to the lysosome. It is noteworthy that glycoGALNS allowed the reduction of KS in Morquio A fibroblasts. Finally, the biodistribution assay in C57BL/6 wild type mice showed that this recombinant GALNS was mainly distributed to kidney after 24 hours posttreatment. In summary, these results showed the potential of glycoGALNS towards the development of a new enzyme replacement therapy for Morquio A disease.
661 - Phenotypic Characterization and Neuroimaging Findings in a Case Series of Three Patients With Mucopolysaccharidosis VI (Maroteaux-Lamy Syndrome) in Ireland
Ina Knerr1, Claire Thompson1, Aida Abedin1, Caroline Moloney1, Ellen Crushell1, Eileen Treacy1, Stephanie Ryan2, and Ardeshir Monavari1
1NCIMD, Children’s University Hospital, Dublin, Ireland
2Radiology Dep., Children’s University Hospital, Dublin, Ireland
662 - Presenting Signs and Symptoms of MPS: Results of a Systematic Literature Analysis
Fathima Mubarack1, Lorne Clarke2, Carolyn Ellaway3, Helen Foster4, Roberto Giugliani5, Cyril Goizet6, Sarah Goring7, Sara Hawley1, Elaina Jurecki1, Zaeem Khan7, Christina Lampe8, Ken Martin9, Suzanne Mcmullen7, John Mitchell10, Joseph Muenzer11, Serap Sivri12, Fiona J. Stewart13, Anna Tylki-Szymanska14, Klane White15, and Frits Wijburg16
1Biomarin Pharmaceutical Inc., Novato, CA, USA
2British Columbia Children’s Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
3Sydney Children’s Hospital Network, Sydney University, Sydney, Australia
4Newcastle Upon Tyne Nhs Hospitals Foundation Trust and Newcastle University, Newcastle Upon Tyne, United Kingdom
5Med Genet Serv Hcpa, Dep Genet Ufrgs & Inagemp, Porto Alegre, RS, Brazil
6University Hospital of Bordeaux, Bordeaux University, Bordeaux, France
7Icon Plc, Vancouver, Canada
8Centre for Rare Diseases, Clinic for Children and Adolescents, Helios Dr. Horst Schmidt Kliniken, Wiesbaden, Germany
9Ucsf Benioff Children's Hospital Oakland, Oakland, CA, USA
10Montreal Children's Hospital, Quebec, Canada
11University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
12Hacettepe University Children's Hospital, Ankara, Turkey
13Belfast City Hospital, Belfast, United Kingdom
14Children's Memorial Health Institute, Warsaw, Poland
15Seattle Children's Hospital, Seattle, WA, USA
16Academic Medical Center, University Hospital of Amsterdam, Amsterdam, the Netherlands
663 - Cellular Localization of Iduronate-2-Sulfatase, Proteome Isolation, and Identification of Changes in the Proteomic Profiling in a Murine Model of Hunter Syndrome
Carolina Cardona Ramírez, Eliana Benincore-Flórez, Luisa Natalia Pimentel Vera, Edwin Alexander Rodríguez, Luis Humberto Reyes, Camilo Patarroyo, Luis Alejandro Barrera, and Carlos Alméciga-Díaz1
Instituto de Errores Innatos Del Metabolismo, Bogotá, Colombia
Iduronate-2-sulfatase (IDS) is a lysosomal enzyme that participates in the metabolism of heparan and dermatan sulfate. Mutations on IDS gene produce mucopolysaccharidosis II (MPSII). This pathology is characterized by intracellular accumulation of both substrates causing severe damage to the central nervous system and other tissues. In this study, we used a neurochemistry and proteomic approach to identify the brain distribution of IDS, as well as its interacting proteins to get insights into the physiological role of this protein in brain. The IDS brain distribution was evaluated by immunodetection methods. Brain IDS proteome was isolated by using a recombinant IDS produced in Pichia pastoris, which was purified by anion exchange and molecular exclusion chromatography. The isolation of IDS-interacting partners was carried out with IDS-sepharose affinity chromatography
664 - Improvement of the Quality of Life With Use of Enzyme Replacement Therapy in a Wheelchair Patient With Morquio A Syndrome
Helena Pimentel, Melissa Dumas, and Ana Alzira Sobral
Hospital Roberto Santos, Salvador, BA, Brazil
665 - Trajectory of Patients With Mucopolysaccharidosis, “From Symptom to Diagnosis”
Marcela Pereyra1, Jimena Dri1, Ana Guercio1, Cristina Gatica1, and Griselda Ray2
1Pediatric Hospital “Dr. H. J. Notti”, Mendoza, Argentina
2“Pediatric Hospital A. Fleming”, Mendoza, Argentina
666 - Mutation Prediction Analysis Across the MPS Genes
Gabriela Pasqualim1, Pâmella Borges2, Delva Leão2, Roberto Giugliani3, and Ursula Matte2
1Postgraduate Program in Genetics and Molecular Biology, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
2Gene Therapy Center, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
3Medical Genetics Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
Mucopolysaccharidoses (MPS) are rare monogenic disorders caused by genetic alterations in enzymes involved in degradation of glycosaminoglycans. With molecular diagnostic advance, the number of new variants of uncertain significance (VUS) described in these genes increases daily. Diverse programs exist for pathogenicity evaluation. However, discordant results are frequently found. Therefore, the purpose of this study was to compare different prediction software in the evaluation of missense alterations of genes associated with MPS.
667 - Molecular Characterization of MPS IVA Patients in Andean Region of Colombia
Harry Pachajoa1, Estephania Candelo1, Gabriela Caicedo-Herrera1, Diana Ramirez2, Lorena Diaz-Ordonez2, Carlos Andres Zapata Chica3, and Gloria Liliana Porras Hurtado3
1Ciacer, Universidad Icesi And Fundación Valle Del Lili, Cali, Colombia
2Ciacer, Universidad Icesi, Cali, Colombia
3Comfamiliar Clinic, Pereira, Colombia
668 - Hurler Syndrome, Clinical Characterization of a New Molecular Variant Identified in a Colombian Patient
Harry Pachajoa1, Sara Vanegas2, Diana Ramirez2, and Estephania Candelo2
1Ciacer, Universidad Icesi and Fundación Valle Del Lili, Cali, Colombia
2Ciacer, Universidad Icesi, Cali, Colombia
669- Alpha-Mannosidosis in a Patient With Mild Phenotype and Nonsense Mutation
Carmen Mendes1, Maret Rand1, Marco Curiati1, Maryana Marins2, Joao Pesquero2, and Ana Maria Martins1
1Centro de Referencia em Erros Inatos do Metabolismo Unifesp, Sao Paulo, SP, Brazil
2Centro de Pesquisa e Diagnostico Molecular em Doenças Genéticas Unifesp, Sao Paulo, SP, Brazil
670 - Molecular Genetics Profile of Mucopolysaccharidoses in the State of Santa Catarina, Brazil
Louise Pinto1, Jose Goes1, Francisca Ligia Carvalho1, Gisele Luca1, Sandra Leistner-Segal2, Ana Carolina Brusius-Facchin2, and Roberto Giugliani2
1Hospital Infantil Joana de Gusmao, Florianopolis, SC, Brazil
2Hospital de Clinicas de Porto Alegre, Porto Alegre, RS, Brazil
671 - Effect of Losartan on Cardiovascular Disease in MPS I Mice
Esteban Gonzalez1, Angela Tavares2, Edina Poletto1, Roberto Giugliani3, Ursula Matte4, and Guilherme Baldo4
1Postgraduate Program in Genetics and Molecular Biology, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
2Postgraduate Program in Physiology, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
3Medical Genetics Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, RS, Brazil
4Gene Therapy Center, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
Mucopolysaccharidosis type I (MPS I) is a lysosomal storage disorder caused by deficiency of alpha-L-iduronidase. Aortic dilatation and heart enlargement are common features in MPS I patients. Alterations of TGF-β pathway have been related to cardiovascular diseases and it may be associated to MPS I heart dysfunction. Based on this, we verified the effects of blocking the TGF-β pathway with losartan on cardiovascular disease in a murine model of MPS I. MPS I mice were treated with losartan at 2 months of age (0.6 g/L in drinking water; n = 11) or propranolol (0.5 g/L; n = 5). Wild-type (WT) and untreated MPS I mice were used as controls (n = 12 each). All animals underwent ultrasound examination at 6 months of age before euthanasia. Echocardiography analyses were performed to determine the left ventricular (LV) dimensions and cardiac function by shortening fraction (LVSF). Pulmonary vascular resistance (PVR) was obtained as the ratio between the acceleration and ejection times (AT/ET) at the pulmonary valve. Aortic root diameter was determined by M-mode, and in situ using a digital caliper immediately after euthanasia. Cardiovascular tissues were embedded in paraffin. Sections were stained with H-E & Alcian Blue to determined valve thickness or Verhoef Van Gieson (VVG) to analyze elastin breaks in the aorta. Aortic root diameter was increased 67% in MPS I mice compared to WT (1.07 mm ± 0.13 vs 1.79 mm ± 0.25; P < .01). Losartan decreased 25% the aortic diameter compared to MPS I (1.34 mm ± 0.15; P < .01). Echo analysis showed that losartan also improved the LVSF and the AT/ET ratio. MPS I mice presented reduced contractility (36.7% ± 5.1 in WT vs 27.6% ± 3.6, P < .05) while the heart function in treated mice with losartan was similar to WT (34.8% ± 5.7). Losartan treatment also prevented enlargement of the LV. MPS I mice presented increased heart valve thickening (P < .01) and elastin breaks per mm compared to normal mice (P < .01). No effect was observed on the valve thickness, but losartan normalized the elastin breaks. Mice treated with propranolol improved cardiac function and LV dimensions but had no effect on the aorta. We suggest that losartan is a potential new therapy for cardiovascular disease in MPS I. Propranolol only improved cardiac function, which suggests that heart dysfunction may be independent from TGF-β signaling. Losartan may target the underlying pathophysiology in MPS possibly by antagonism of TGF-β or other pathways which will be investigated.
672 - Follow-Up of Patients With Mucopolysaccharisosis Type II and IV With Enzyme Replacement Therapy. A Chilean Referral Center Experience
Monica Troncoso, Diane Vergara, Javiera Tello, Jose Cardenas, Sebastian Silva, Paola Santander, Fernanda Balut, Isadora Ruiz, Veronica Saez, Patricio Guerra, Jose Tomas Mesa, Fernando Pinto, Ignacia Valdes, Monica Fuenzalida, Daniela Sanchez, and Stephanie Valdes
Pediatric Neuropsychiatry Unit, Faculty of Medicine, San Borja Arriarán Hospital, University of Chile, Santiago, Chile
673 - Correlation of Ventriculomegaly, Size of Foramen Magnum and Jugular Foramina, and Cerebral Venous Outflow in Mucopolysaccharidoses
Amauri Dalla-Corte1, Carolina Souza2, Marco Stefani1, Maurício Anés2, Leonardo Vedolin3, Armelle Lokossou4, Eduarda Stefani5, Olivier Balédent4, and Roberto Giugliani1
1Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
2Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
3Dasa, São Paulo, SP, Brazil
4University of Picardie Jules Verne, Amiens, France
5Universidade Luterana do Brasil, Canoas, RS, Brazil
674 - Mucopolysaccharidosis Type VI (MPS VI) and Molecular Analysis: A Review of Published Classified Variants in the ARSB Gene
Litsa Karageorgos1, Rossella Tomanin2, Moeenaldeen Dia Alsayed3, Mitch Bailey4, Emanuela Izzo4, Nicole Miller4, Hitoshi Sakuraba5, Alessandra Zanetti2, and John Hopwood1
1Lysosomal Diseases Research Unit, South Australian Health and Medical Research Institute, Adelaide, Australia
2Laboratory of Diagnosis and Therapy of Lysosomal Disorders, University of Padova, Padova, Italy
3King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
4Biomarin Pharmaceutical Inc., Novato, CA, USA
5Department of Clinical Genetics, Meiji Pharmaceutical University, Tokyo, Japan
675 - Protocol Proposal for Mucopolysaccharidosis (MPS) Risk-Population Screening (MPSRPS) to the Ecuadorian Public Ministry of Health to be Included in the Ecuadorian Health System
Alba Aguilar and Lourdes Pazmiño
Universidad Central Del Ecuador, Quito, Ecuador
Some rare diseases, such as mucopolysaccharidosis (MPS), if they are detected early through access to early screening, this may allow to improve the quality of life of the patient and their family. This allows for them to receive the appropriate medical treatment, if there is access to it, which improves the illness’ prognosis. Ecuador has little development in the management of rare diseases such as MPS at the early detection level as well as its proper treatment. The country offers, since the end of 2011, to the Ecuadorian public a newborn screening called “Con Pie Derecho” (On the Right Foot) Our investigation is aimed to propose a protocol for the Ecuadorian population, from the necessary laboratory tests for screening and diagnosis up until the adequate offer within the first level of attention in the National Health System. In this sense, our investigation work is to deliver a protocol for our health system and includes a protocol proposal for laboratory test for screening and diagnosis with adequate and opportune access for the at-risk population.
676 - Hematopoietic Stem Cell Transplantation for Patients With Mucopolysaccharidosis II
Shunji Tomatsu1, Francyne Kubaski1, Hiromasa Yabe2, Yasuyuki Suzuki3, Toshi Seto4, Takashi Hamazaki4, Robert W. Mason1, Tor Gunnar Hugo Onsten Tonsten5, Sandra Leistner-Segal6, Roberto Giugliani7, Vũ Chí Dũng6, Can Thi Bich Ngoc8, Seiji Yamaguchi9, Adriana M. Montaño10, Kenji E. Orii11, and Tadao Orii11
1nemours/Alfred I. Dupont Hospital for Children, Wilminton, USA
2Tokai University School of Medicine, Isehara, Japan
3GIFU University, GIFU, JAPAN
4Osaka City University Graduate School of Medicine, Osaka, Japan
5Haemotherapy Service, HCPA, Porto Alegre, RS, BRAZIL
6Medical Genetics Service- HCPA, Porto Alegre, RS, Brazil
7INAGEMP, Porto Alegre, RS, Brazil
8Vietnam National Children’s Hospital, Department of Medical Genetics, Metabolism & Endocrinology, Hanoi, Vietnam Do Sul
9Department of Pediatrics, Shimane University, Shimane, Japan
10Department of Pediatrics, Saint Louis University, St. Louis, MO, USA
11Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
T) Lysosomal Disorders: Sphingolipidoses (677 to 736)
677 - Identification of Lysosomal and Extralysosomal Globotriaosylceramide (Gb3) Accumulation in Endomyocardial Biopsies Before the Occurrence of Typical Pathological Changes of Fabry Disease
Dau-Ming Niu1, Ming-Jia Hsu2, Fu-Pang Chang1, Wen-Chung Yu1, Ting-Rong Hsu1, Chih-Ya Cheng1, Chang Sheng-Kai2, and Chia-Lin Hsu2
1Taipei Veterans General Hospital, Taipei, Taiwan, Taipei, Taiwan
2National Yang-Ming University, Taipei, Taiwan, Taipei, Taiwan
678 - BIG Project (Bone Involvement in Gaucher Disease): Screening for Gaucher Disease With Focus in Bone Affection
Paula Rozenfeld1, Diana Gonzalez2, Camilo Lis3, Omar Riemersma3, Martin Kot3, and Beatriz Oliveri4
1Iifp, Universidad Nacional de La Plata, Conicet, Facultad de Ciencias Exactas, Departamento de Ci, La Plata, Argentina
2Mautalen, Salud e Investigación, Bs As Argentina, Buenos Aires, Argentina
3Shire, Buenos Aires, Argentina, Buenos Aires, Argentina
4Laboratorio de Osteoporosis Y Enfermedades Metabólicas Óseas, Instituto de Inmunología, Genética Y M, Buenos Aires, Argentina
Type I Gaucher disease (EG1) is characterized by hematological, visceral and skeletal signs and symptoms. Around 80% to 95% of patients suffer from bone clinical signs or imaging skeletal problems. The clinical suspicion generally is because of hepato/splenomegaly or cytopenia, however some of the patients present in the first physician visit with bone symptoms. The objective is to present a project for medical education and screening for Gaucher disease with focus in bone affection. A diagnosis algorithm was developed based on bone problems. The screening will be done by assaying glucocerebrosidase in dried blood filter paper, and pathological ones will be confirmed in leukocytes in the following patients: 1) below 18 years old with osteomyelitis, recurrent fractures without diagnosis, Perthes disease, recurrent bone crisis or avascular necrosis (AN), 2) between 18 and 50 years old with recurrent fractures without diagnosis, recurrent bone crisis, hip arthroplasty or avascular necrosis (AN), 3) below 50 years old with reduced bone mineral density (Z score < −2) and bone pain without diagnosis with abnormal ferritin and platelet counts. This algorithm will be implemented along with an educational program about early diagnosis and bone affection in Gaucher disease in several centers from Argentina. It is important to improve the dissemination of knowledge among orthopedists, pediatricians, endocrinologists, rheumatologists, and biochemists, in order to improve early detection and diagnosis of Gaucher patients in order to have an early access to specific treatment.
679 - Moving Forward Toward Personalized Medicine in Rare Diseases: Examples From Lysosomal Disorders
Andres Klein
Universidad del Desarrollo, Santiago, Chile
Understanding phenotypic variability in rare genetic diseases, such as Gaucher disease (GD), is challenging because it is hard to recruit large cohorts of patients with different symptoms to perform association studies. To overcome this problem, we chemically induced GD in 15 inbred mouse strains because their SNPs profile are known, followed by GWAS. GD-induced strains mimicked the divergent phenotypes observed in patients, which range from neuropathic disease with short lifespans to others with no evident CNS involvement and longer survival times. GWA analysis identified a small collection of candidate loci underlying the variable strain phenotypes, which allowed us to successfully predict the severity of the disease in other strains upon GD induction and to identify a novel therapy for the neuropathic forms of GD. By the end of the talk, I will discuss other approaches that we are currently following to uncover modifier genes and therapeutically relevant pathways including exome sequencing in twins presenting with different disease severity and multi-omics in fibroblasts derived from patients with other rare lysosomal diseases.
680 - Cause of Genetic Variations in Severe Clinical Phenotypes of Female Fabry Disease
Yoshikatsu Eto1, Arif Hossein2, Takashi Miyajima2, Keiko Akiyama3, Wu Chen2, Rina Itagaki2, Hiroko Yanagisawa2, Takeo Iwamoto4, Kaoru Eto5, Takayuki Yokoi6, Kenji Kurosawa6, Kenji Kurosawa6, Takayuki Yokoi6, Kaoru Eto5, Takeo Iwamoto4, Hiroko Yanagisawa2, Rina Itagaki2, Wu Chen2, Keiko Akiyama3, Takashi Miyajima2, and Arif Hossein2
1Tokyo Jikei University, Tokyo, Japan
2Sourthern Tohoku Brain Research Institute, Kawasaki, Japan
3Sourther Tohoku Brain Research Institute, Kawasaki, Japan
4Core Research Facilities for Basic Science, Jikei Univ, Tokyo, Japan
5Department of Pediatrics, Tokto Womens Medical University, Tokyo, Japan
6Kanagawa Children Medical Center, Kanagawa, Japan
Clinical spectrum of female Fabry disease shows wide range of clinical pictures. Generally, female clinical phenotype is caused by the degree of skewed X percentage of α-Gal A gene/ percentage of residual α-Gal enzyme activities. However, there are severe clinical phenotypes of female Fabry disease, almost equivalent to those of classical type of male Fabry disease. These severe clinical phenotypes are caused by main three factors: 1) The X screwed degree of methylation of alfa-Gal A gene in female- a case with complete methylated allele in alfa-Gal A gene. 2) Cases associated with Turner syndrome, XO/Mosaic show severe clinical phenotypes. 3) Compound heterozygote/ homozygote states in two alleles of alfa-Gal A gene. Present report concerns unique severe clinical phenotype, a 37-year-old female Fabry disease associated with mental retardation and coarse face. Mild cardiomegaly was observed with mild proteinuria. Electron microscopic examination of skin demonstrated massive lamellar inclusion bodies in various skin cells. Chromosomal analysis showed chromosome 10q26 micro deletion demonstrated by CGH array which leads to mental retardation. Furthermore, plasma lyso Gb3 was markedly increased, more than 10 times of controls and this patient also excreted large amount of urinary Gb3 and Gb2 which showed more than classical male patient, her gene mutation was identified in exon 1, c36C>A. Furthermore, this patient showed complete methylation of alfa-Gal A gene in CpG island at exon 1 which leads to zero activity of alfa-Gal in leukocytes. This unique female is first case with complete methylated allele of alfa-Gal A gene associated with chromosome 10q26 deletion syndrome. Female Fabry disease associated with Turner syndrome, compound/homozygote state of female gene mutations or methylation occurred in non- mutated allele of alfa-Gal gene which caused complete inactivation of alfa-Gal enzyme activity, sometimes showed serious clinical course such as cardiac failure and CNS problems, and also may not response well to enzyme replacement therapy because of higher titer of serum antibody formation against enzyme protein. In practical point of view, it is important to take an account these clinical conditions in severe clinical phenotype of female Fabry disease.
681 - Report of a Novel Mutation in the Human GLA gene (Fabry disease) in the Same Family With 3 Female Generations Affected
Maria Amparo Acosta Aragon
Paediatrics Department, Cauca University School of Medicine, San Joseph Hospital, Popayan, Colombia
Lysosomal diseases originate in synthesis or function disorders of a lysosomal acid hydrolases. Fabry is an X linked hereditary defect of glycosphingolipid storage caused by mutations in the gene encoding the lysosomal acid hydrolase alfa-galactosidase A (GLA, alfa-galA). To date, over 400 mutations causing amino acid substitutions have been described. Some of these mutations are not related to the classical Fabry phenotype especially in women. We identified by molecular study 3 female patients belong three different generations in the same family at Cauca Department (Southwest from Colombia) with high values of Lyso-Gb3 and the heterozygous mutation (c.1124G>p.G375A). The clinical symptoms include chronic renal failure (index case of 54 years old, grandmother), hypohidrosis, microalbuminuria, acroparesthesias, cornea verticillata (index case of 35 years old, mother) and a positive microalbuminuria test (index case of 3 years old, grand-daughter). We conclude the three patients are suffering from Fabry disease, due to a new mutation in the GLA gene, recently classified as pathogenic.
682 - Cardiac Manifestations in Niemann-Pick Type C Disease With Mutations in the NPC1 Gene: Case Report
Mara Lucia Santos, Eliana Pellissari, Darken Oliveira, Daniel Valle, Ana Gabriela Bicalho, Fernanda Colomé, Joselainy Galeazzi, Júlia Maria Lopes, Leticia Kabashima, Paula Gomes, and Thalita Cecilia Lima
Hospital Pequeno Príncipe, Curitiba, PR, Brazil
The present study is the first report of Niemann-Pick type C with mutations in the NPC1 gene with cardiac manifestation. We present a male patient, from a nonconsanguineous family with diagnosis of Niemann-Pick type C at 7 years old. At 13 years old, a discrete cardiomegaly was identified in a routine echocardiogram, with no prejudice in left ventricular function. A discrete left ventricular hypertrophy was identify in follow up. A mild diastolic dysfunction was identify in 2016. At 16 years old, a new echocardiogram was performed showing a mild left ventricular concentric remodeling with an interventricular septal hypertrophy. Left ventricle mass of 115 g (Z > 2.0) and in wall thickness of 0.42 (Z > 2.0). Niemann-Pick disease type C is an autosomal recessive disease due to mutation in the NPC1 and NPC2 genes leading to alterations in trafficking of endocytosed cholesterol and storage of glycosphingolipids in tissues. Cardiac involvement is a common in others lysosomal storage diseases, but, till data, none cardiac involvement was describe in Niemann-Pick type C patients. This case report provides important new information about cardiac involvement in a patient with Niemann-Pick type C and advance the understanding of this disease.
683 - Evaluation of Endothelial Function With Reactive Hyperemia-Digital Peripheral Arterial Tonometry as a Non-Invasive Biomarker to Reflect Vascular Pathology in Patients With Fabry Disease
Shoji Yano, Kathryn Moseley, and Colleen Azen
University of Southern California, Los Angeles, CA, USA
684 - A Rare Form of GM1-Gangliosidosis: The Late Infantile Variant
Sahin Erdol, Sevil Dorum, and Halil Saglam
Uludag University Faculty of Medicine, Bursa, Turkey
685 - Evaluation of Enzyme Replacement Therapy for Bone Lesions of Gaucher Disease
Kazuya Tsuboi and Hiroshi Yamamoto
Nagoya Central Hospital, Nagoya, Japan
686 - Physician Awareness of Gaucher Disease in Indonesia
Cut Nurul Hafifah1, Klara Yuliarti1, Titis Prawitasari1, Lanny Christine Gultom2, Damayanti Rusli Sjarif1
1Div Ped Nutr Metab Dis, Dept Pediatrics, Cipto Mangunkusumo Hosp, Univ Indonesia, Jakarta, Indonesia
2Div Ped Nutr Metab Dis, Dept Pediatrics, Fatmawati Hosp, Jakarta, Indonesia
Gaucher disease is the most common lysosomal storage disease. However, awareness of this disease in developing countries, such as Indonesia, is still low, while treatment options are also limited. There should be more than 4000 cases in Indonesia, considering Indonesia’s population of 250 million.
687 - Assessing the Effectiveness of Miglustat in Niemann-Pick Disease Type C
Mercè Pineda1, Mark Walterfang2, and Marc Patterson3
1Fundacio Hospital Sant Joan de Déu, Barcelona, Spain
2Royal Melbourne Hospital, Melbourne, Australia
3Mayo Clinic, Rochester, MN, USA
688 - A Randomized Controlled Trial of Two Low-Dose Agalsidase Beta Regimens in Male Pediatric Patients With Fabry disease: GL-3 Clearance From Kidney Cells
Uma Ramaswami1, Bernard Bénichou2, Daniel G Bichet3, Lorne Clarke4, Gabriela Dostalova5, Alejandro Fainboim6, Andreas Fellgiebel7, Cassiano Forcelini8, Kristina An Haack9, Robert J Hopkin10, Michael Mauer11, Behzad Najafian11, C Ronald Scott12, Suma P Shankar13, Beth L Thurberg14, Camilla Tøndel15, Anna Tylki-Szymanska16, and Frits Wijburg17
1Royal Free London Nhs Foundation Trust, University College of London, London, United Kingdom
2Formerly Sanofi Genzyme, Saint-Germain-En-Laye Cedex, France
3Hôpital Du Sacré-Coeur de Montréal and University of Montreal, Montreal, Canada
4University of British Columbia, Child and Family Research Institute, Vancouver, Canada
5Charles University Prague, General University Hospital Prague, Prague, Czech Republic
6Hospital de Niños Ricardo Gutierrez, Hospital de Dia Polivalente, Ciudad Autónoma de Buenos Aires, Buenos Aires, Argentina
7Rheinhessen-Fachklinik Alzey, Alzey, Germany
8Hospital São Vicente de Paulo, Passo Fundo, RS, Brazil
9Sanofi Genzyme, Chilly-Mazarin, France
10Cincinnati Children's Hospital Medical Center, and University of Cincinnati College Medicine, Cincinnati, OH, USA
11University of Minnesota, Minneapolis, MN, USA
12University of Washington, Seattle, WA, USA
13Emory University School of Medicine, Decatur, Currently at Uc Davis School of Medicine, Sacramento, CA, USA
14Sanofi Genzyme, Framingham, MA, USA
15Haukeland University Hospital, Bergen, Norway
16Żywienia I Chorób Metabolicznych Instytut Pomnik Centrum Zdrowia Dziecka, Warsaw, Poland
17Academic Medical Center, University Hospital of Amsterdam, Amsterdam, the Netherlands
Fabry disease is a multisystem, X-linked disorder caused by deficient α-galactosidase A activity. Progressive accumulation of globotriaosylceramide (GL-3) starts early in life in multiple tissues, including the kidney. This is a 5-year study of the efficacy of agalsidase beta low-dose regimens (0.5 mg/kg 2-weekly [0.5q2w, n = 16] or 1 mg/kg 4-weekly [1q4w, n = 15]) in pediatric male patients without clinically evident vital-organ involvement (NCT00701415). Exploratory outcomes included renal function (microalbuminuria, proteinuria, glomerular filtration rate [GFR, iohexol elimination]), retinal imaging (dilatation, tortuosity), angiokeratomas, plasma/urine biomarkers, and optional renal biopsies at baseline and year 5. Data are presented on 7/31 patients who had paired kidney biopsies. Median age of these 7 patients at baseline was 15 (range 10–17) years. Semi quantitative light microscopy GL-3 scoring showed complete GL-3 clearance in 6/8 kidney cell types assessed at year 5. Clearance was incomplete in non-capillary smooth muscle cells (2/7 patients) and podocytes (4/7 patients). Absolute podocyte GL-3 inclusions volume (quantitative electron microscopy) decreased in 4 patients (3 on 0.5q2w, 1 on 1q4w) and increased in 3 (1 on 0.5q2w, 2 on 1q4w). These changes did not correlate with peak anti-α-galactosidase antibody titers (median 400, range: 0-12,800), kidney function, or podocyte injury. Fabry arteriopathy severity increased in 6/7 patients. No significant development of interstitial fibrosis or glomerulosclerosis was observed. In all 7 patients, plasma and urine GL-3 levels rapidly normalized, and lyso-GL-3 levels reduced to near normal, with fluctuations after year 2. Renal function remained normal. All had retinal vessel involvement at baseline with no substantial changes at year 5. Angiokeratomas worsened in 5/7 patients. Estimated GFR values using the CKD-EPI formula in patients ≥18 years were distinctly higher than values measured by the Bedside Schwartz formula in patients <18 years. In conclusion, despite normal renal function, renal histological and retinal vessel abnormalities were present at baseline. Low-dose agalsidase beta regimens appeared sufficient to clear GL-3 from 6/8 renal cell types examined, but with variable reductions of podocyte GL-3 in both low-dose regimens. These observations suggest that podocyte GL-3 clearance could be agalsidase beta dose dependent.
689 - Final Efficacy and Safety Results From a Phase 2 Clinical Trial After 8 Years of Treatment With Oral Eliglustat in Treatment-Naïve Adults With Gaucher Disease Type 1
M. Judith Peterschmitt1, Nora Watman2, Marta Dragosky3, Heather Lau4, Elsa Avila Arreguin5, Hanna Rosenbaum6, Yaoshi Wu1, Sebastiaan Gaemers1, and Elena Lukina7
1Sanofi Genzyme, Cambridge, MA, USA
2Hospital Ramos Mejua, Biuenos Aires, Argentina
3Imai-Research, Buenos Aires, Argentina
4New York University School of Medicine, New York, NY, USA
5Instituto Mexicano del Seguro Social Hospital de Especialidades, Col. La Raza, Mexico
6Rambam Medical Center, Haifa, Israel
7National Research Center for Hematology, Moscow, Russia
Eliglustat is an oral substrate reduction therapy approved as first-line treatment for adults with Gaucher disease type 1 (GD1) with poor, intermediate, or extensive CYP2D6-metabolizer phenotypes (>90% of patients). We report final long-term efficacy and safety results of a Phase 2 trial (NCT00358150, Sanofi Genzyme) after 8 years of eliglustat treatment in previously untreated patients. Adult GD1 patients who had splenomegaly with thrombocytopenia and/or anemia received 50 or 100 mg eliglustat tartrate (equivalent to 42 or 84 mg eliglustat) twice daily, dosed by plasma trough levels. Efficacy outcomes included changes in hemoglobin, platelets, spleen and liver volumes, disease-related biomarkers, skeletal manifestations, and achievement of therapeutic goals for anemia, thrombocytopenia, splenomegaly, and hepatomegaly (Pastores. Semin Hematol. 2004; Lukina. Blood. 2010). Of 26 enrolled patients, 19 completed the trial and 7 withdrew: 2 due to asymptomatic nonsustained ventricular tachycardia detected during 36-hour ECG safety monitoring on Day 1 (plasma drug levels were undetectable); 1 after 1 year due to progression of a bone lesion retrospectively identified at baseline; 1 chose to withdraw after 2 years; and 3 due to pregnancy. After 8 years of eliglustat, mean ± SD hemoglobin and platelet count increased by 2.1 ± 1.7 g/dL (from 11.3 ± 1.6 to 13.4 ± 1.3 g/dL) and 110% (from 67.5 ± 21.1 to 130.7 ± 59.8 ×109/L), respectively. Mean spleen and liver volumes decreased by 68% (from 17.3 ± 10.4 to 5.1 ± 3.5 multiples of normal [MN]) and 31% (from 1.6 ± 0.5 to 1.1 ± 0.3 MN), respectively. All patients met
690 - Liver-Based Expression of the Human Alpha-Galactosidase A Gene in a Murine Fabry Model Results in Continuous Therapeutic Levels of Enzyme Activity and Effective Substrate Reduction
Thomas Wechsler
Sangamo Therapeutics, Richmond, CA, USA
Fabry disease (FD) is an X-linked lysosomal storage disease caused by mutations in the GLA gene encoding alpha galactosidase A (α-GalA). FD is characterized by progressive systemic accumulation of α-GalA’s substrates, globotriaosylceramide (Gb3) and lyso-Gb3, leading to renal, cardiac and cerebrovascular disease, leading to premature demise. The mutation and any residual α-GalA enzyme level determine whether the disease presents as classic FD or as later onset phenotypes. FD is treated by enzyme replacement therapy (ERT) by lifelong biweekly infusions, with variable results. Thus, an improved, more effective, and long-lasting treatment is needed. Two AAV-mediated, liver-targeted gene therapies were evaluated in a mouse model (GLAKO) lacking α-GalA activity, resulting in high levels of Gb3/lyso-Gb3 in plasma and tissues. The first strategy employs an episomal AAV vector encoding human GLA cDNA (hGLA) driven by a liver-specific promoter. Vector administration led to supraphysiological (up to 50-fold of WT) plasma α-GalA levels at day 14 sustained continuously for up to 6 months. At study end, dose-dependent α-GalA activity was increased in liver, heart, kidney and spleen with a corresponding reduction of Gb3/lyso-Gb3 to near normal levels. The second strategy (currently in clinical studies for Hemophilia B and Mucopolysaccharidoses) uses Zinc-Finger Nuclease (ZFN)-mediated genome editing to permanently integrate a corrective hGLA gene in the Albumin locus in liver cells. This strategy exploits the high transcriptional activity of this locus to create stably modified hepatocytes with potentially life-long transgene expression. Administration of 3 AAV vectors (2x ZFN vectors, 1x hGLA cDNA vector) achieved supraphysiological levels of up to 50-fold of WT of α-GalA activity in plasma (sustained for duration of the 2 month study) and high activity levels in liver, heart, kidney and spleen. Gb3 in these tissues averaged <10% of that measured in untreated mice. Importantly, appropriate glycosylation of the α-GalA enzyme was confirmed to ensure efficient lysosomal uptake in target tissues. Thus “proof-of-concept” for use of AAV-mediated targeting of hepatocytes to express therapeutic levels of human α-GalA has been demonstrated. A marked reduction of pathological accumulated Gb3/lyso Gb3 in key tissue sites was found, further supporting our liver-based AAV approaches as potential therapies for FD.
691 - Case Report: Niemann Pick C 1 Mutations: Exon 20 (c.3019CG) and Exon 22 (c.3249_3250delGT)
Maria Del Carmen Martinez Perea
Hospital Rivadavia, Buenos Aires, Argentina
692 - GALAC Deficiency in Pediatric and Juvenile Patient (Krabbe disease)
Maria Del Carmen Martinez Perea, Yancovich Spasoje, Natalia Pugliese, Darío Adamec, and Emma Taboada Carrillo
Hospital B. Rivadavia, Buenos Aires, Argentina
693 - A Randomized Controlled Trial of Two Low-Dose Agalsidase Beta Regimens in Male Pediatric Patients With Fabry disease: GL-3 Clearance From Superficial Skin Capillary Endothelium
Uma Ramaswami1, Bernard Bénichou2, Daniel G Bichet3, Lorne Clarke4, Gabriela Dostalova5, Alejandro Fainboim6, Andreas Fellgiebel7, Cassiano Forcelini8, Kristina An Haack9, Robert J Hopkin10, Michael Mauer11, Behzad Najafian11, C Ronald Scott12, Suma P Shankar13, Beth L Thurberg14, Camilla Tøndel15, Anna Tylki-Szymanska16, and Frits Wijburg17
1Royal Free London Nhs Foundation Trust, University College of London, London, United Kingdom
2Formerly Sanofi Genzyme, Saint-Germain-En-Laye Cedex, France
3Hôpital Du Sacré-Coeur de Montréal and University of Montreal, Montreal, Quebec, Canada
4University of British Columbia, Child and Family Research Institute, Vancouver, British Columbia, Canada
5Charles University Prague, General University Hospital Prague, Prague, Czech Republic
6Hospital de Niños Ricardo Gutierrez, Hospital de Dia Polivalente, Ciudad Autónoma de Buenos Aires, Buenos Aires, Argentina
7Rheinhessen-Fachklinik Alzey, Alzey, Germany
8Hospital São Vicente de Paulo, Passo Fundo, RS, Brazil
9Sanofi Genzyme, Chilly-Mazarin, France
10Cincinnati Children's Hospital Medical Center, And University of Cincinnati College Medicine, Cincinnati, OH, USA
11University of Minnesota, Minneapolis, MN, USA
12University of Washington, Seattle, WA, USA
13Emory University School of Medicine, Decatur, Currently at UC Davis School of Medicine, Sacramento, CA, USA
14Sanofi Genzyme, Framingham, MA, USA
15Haukeland University Hospital, Bergen, Norway
16Żywienia I Chorób Metabolicznych Instytut Pomnik Centrum Zdrowia Dziecka, Warsaw, Poland
17Academic Medical Center, University Hospital of Amsterdam, Amsterdam, the Netherlands
Fabry disease is an X-linked disorder caused by GLA mutations that reduce α-galactosidase A activity. Progressive lysosomal accumulation of globotriaosylceramide (GL-3) starts early in life and occurs in a variety of cell types, including capillary endothelial cells, renal, cardiac and nerve cells. This study (NCT00701415) evaluated the efficacy of two agalsidase beta low-dose regimens (0.5 mg/kg 2-weekly [0.5q2w, n = 16] or 1 mg/kg 4-weekly [1q4w, n = 15]) administered for 5 years in pediatric male patients without clinically evident vital-organ involvement. The primary outcome was GL-3 clearance from the superficial skin capillary endothelium (SSCE). Skin biopsies (baseline, years 1, 3, and 5) were available for 29/31 boys (including 2 who received dose increases to 1 mg/kg q2w [labeled dose] for clinical deterioration; excluding 2 drop-outs). The patients’ median age was 13 (range 5-18) years; 11 had a truncating GLA mutation (0.5q2w: 3; 1q4w: 8) and 18 a non-truncating mutation. No patient had severe SSCE GL-3 accumulation (score 3) at any time point. Of the 20 out of 29 patients with a non-0 SSCE GL-3 score at baseline, 13 (65%) reached and maintained 0-scores on low-dose agalsidase beta (0.5q2w: 7; 1q4w: 6). Shifts from baseline non-0 to 0-scores for SSCE GL-3 were statistically significant at each time point in the overall study population and both treatment groups, except at year 5 in the 1q4w group. 6 of the 7 patients with baseline 0-score maintained 0-scores (0.5q2w: 2, 1q4w: 4). The shift from non-0 to 0-score was also significant for GL-3 in deep vessel endothelial cells. Patients with the highest peak anti-α-galactosidase IgG titers tended to show less robust SSCE GL-3 clearance. Two patients with dose increases to 1 mg/kg q2w showed complete, sustained SSCE GL-3 clearance, despite one of them having the highest peak IgG titer (102400). In summary, low-dose agalsidase beta showed variable clearance of SSCE GL-3, compared to those seen with agalsidase beta 1 mg/kg q2w (Germain et al. 2007, Wraith et al. 2008), suggesting possibly a dose-response effect for agalsidase beta. Funding (study and abstract): Sanofi Genzyme.
694 - Long Term Effects of Enzyme Replacement Therapy in an Algerian Cohort of Type 3 Gaucher Patients
Amel Hadji Lehtihet, Samia Sokhal, Nassiba Benali-Khoudja, Rania Saddik, and Rachida Boukari
University of Medicine, Algiers, Algeria
Type 3 Gaucher disease is very rare and it is characterized by a slowly progressive brain involvement, in addition to severe disease of the other organs of the body. Enzyme replacement therapy (ERT) has been demonstrated to be effective in non-neuropathic Gaucher disease, but long-term results in patients with GD3 are still limited.
695 - Cognitive Impairments and Subjective Cognitive Complaints in Fabry Disease
Josefine Loeb1, Ulla Feldt-Rasmussen2, Christoffer V Madsen2, and Asmus Vogel1
1Danish Dementia Research Center, Department of Neurology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
2Department of Medical Endocrinology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
The X-linked Fabry disease is a lysosomal storage disease with progressive organ affections, including cerebral vascular disease. Many patients complain of cognitive disturbance and have a general tendency of non-compliance to treatment and follow-up. Our hypothesis was that Fabry patients have cognitive deficits to a degree that interferes with their ability to perform complex aspects of activities of daily living. Patients (n = 41, 71% females, mean age 47 years, range 20-75) were recruited from the Danish national Fabry cohort. Time from onset of symptoms were from 0-69 yrs (mean 28), alpha-GAL activity was 11.8 nmol/h/mg protein (range 0-33, reference range: 20-65), and MSSI Fabry score was 23.3 ranging from 1 to 42. Memory was assessed by Selective Reminding Test and the Rey Complex Figure Test. Psychomotor speed/attention was assessed by Trail Making Test A & B and Symbol Digit Modalities Test (SDMT). Executive functions were assessed with the Stroop test (100 items), and verbal fluency tests. Cognitive complaints were assessed with Perceived Deficits Questionnaire (PDQ), a self-report measure with 20 questions to be scored in four categories, 0 = never to 4 = almost always. Total score ranges from 0 to 80. Perceived cognitive deficits vary among healthy persons and in this study more than two standard deviations (PDQ score >40) greater than previously found in healthy persons was considered abnormal. According to an a priori definition of cognitive impairment, 12 patients (29.3%) were cognitively impaired (all of them were impaired on ≥ four cognitive tests). The results demonstrated that psychomotor speed and attention had the highest frequency of impairment, as assessed by Stroop test, SDMT and Trail Making Test B. The patients were generally not impaired on memory tests. In general, disease related variables did not have a significant impact on the categorization of patients as being cognitively impaired or non-impaired. The levels of subjective cognitive complaints were generally very low in studied patients. Patients with cognitive deficits did not have significantly more complaints of cognitive dysfunction than healthy controls, Thus, about 1/3 of patients with Fabry disease have cognitive test-performances in a range where it may have a significant impact on everyday functioning and absence of subjective cognitive complaints does not exclude the presence of cognitive problems.
696 - Lysosomal-nucleus players in Fabry disease cultured fibroblasts
Nadia A. Gomez1, Edgar J. Paredes-Gamero2, Vânia D’Almeida1
1Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil
2Universidade de Mogi das Cruzes, Mogi das Cruzes, SP, Brazil
697 - Once Versus Twice-Daily Dosing of Eliglustat in Patients With Gaucher disease Type 1: The Phase 3, Randomized, Double-Blind EDGE Trial
Alexandre Nonino1, Joel Charrow2, Cristina Fraga3, Xuefan Gu4, Hiroyuki Ida5, Nicola Longo6, Elena Lukina7, Sebastiaan Gaemers8, Marie-Hélène Jouvin8, Jing Li8, Yaoshi Wu8, Yong Xue8, and M. Judith Peterschmitt8
1Centro de Cancer de Brasilia (Cettro), Brasilia, DF, Brazil
2Northwestern University Feinberg School of Medicine, Ann And Robert H. Lurie Children’s Hospital, Chicago, IL, USA
3Hdes Hospital, Ponta Delgada, Portugal
4Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China Popular Republic
5The Jikei University School of Medicine, Tokyo, Japan
6University of Utah School of Medicine, Salt Lake City, UT, USA
7National Research Center for Hematology, Moscow, Russia
8Sanofi Genzyme, Cambridge, MA, USA
Eliglustat is a first-line oral therapy for adults with Gaucher disease type 1 (GD1) and compatible CYP2D6 phenotypes (>90% of patients). The randomized, double-blind EDGE trial (Sanofi Genzyme NCT01074944) evaluated once-daily (QD) dosing compared with the approved twice-daily (BID) regimen of eliglustat in previously treated or untreated adults with GD1 who attained clinical stability on BID dosing during a 6 to 18 months lead-in period (LIP). To be randomized to the 1-year primary analysis period (PAP), patients had to attain prespecified therapeutic goals for hemoglobin, platelets, spleen and liver volume, and bone on a stable dose of 50 or 100 mg BID, and have peak plasma eliglustat <50 ng/mL in the LIP. To meet the PAP primary endpoint, per-protocol patients had to maintain stability relative to PAP baseline in 5 measures (no decrease in hemoglobin >1.5 g/dL; no decrease in platelet count >25%; no increase in spleen or liver volume >25% or >20%, respectively; no symptomatic bone disease), and meet tolerability requirements including maintaining plasma eliglustat <150 ng/mL. Non-inferiority of QD vs BID dosing (primary endpoint) was determined by a difference of <−15% in the lower bound of the 95% confidence interval (CI) of the difference between percent stable on QD vs BID. All patients, including non-randomized patients, could continue in an open-label extension. Of 170 enrolled patients, 87% had prior enzyme replacement therapy (ERT); 157 (92%) completed the LIP; 131 met all 5 therapeutic goals and other randomization criteria and entered the PAP. After 1 year, QD dosing did not meet the criteria to be declared non-inferior to BID dosing in tolerability and clinical stability. The lower bound of the 95% CI difference between percent stable on QD vs BID (80% vs 83%) was -17.7%. Randomized patients (QD and BID) maintained mean values for hematologic and visceral measures within therapeutic goal thresholds established for patients on ERT (Pastores et al. Semin Hematol 2004) during the PAP and extension. Eliglustat was well-tolerated in this long-term trial encompassing 566 patient-years of eliglustat exposure, with 4 withdrawals (2%) for related adverse events (AE), and similar AE profiles for QD vs BID. The dose regimen specified in the drug label is confirmed by this study. Although QD dosing did not meet non-inferiority criteria, overall clinical stability and safety for both QD and BID dosing was consistent with other clinical trials of eliglustat.
698 - Guidelines for the Management of Patients With Acid Sphingomyelinase Deficiency
Eugen Mengel1, Melissa Wasserstein2, Carlo Dionisi Vici3, Roberto Giugliani4, Wuh-Liang Hwu5, Olivier Lidove6, Zoltan Lukacs7, Margaret Mcgovern8, Pramod Mistry9, and Edward Schuchman10
1Medical Center of the Johannes Gutenberg University, Mainz, Germany
2Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA
3Hospital Bambino Gesu, Rome, Italy
4Medical Genetics Service, Hcpa, Porto Alegre, RS, Brazil
5National Taiwan University Hospital, Taipei, Taiwan
6Hopital de La Croix St Simon, Paris, France
7University Medical Center Hamburg-Eppendorf, Hamburg, Germany
8Stony Brook University School of Medicine, Stony Brook, NY, USA
9Yale University School of Medicine, New Haven, CT, USA
10Icahn School of Medicine At Mt. Sinai, New York, NY, USA
699 - Safety and Efficacy of Intrathecal Delivery of Recombinant Human Arylsulfatase A Produced Using a Revised Manufacturing Process in Children With Late-Infantile Metachromatic Leukodystrophy
Roberto Giugliani1, Caroline Sevin2, Christine Dali3, Ingeborg Krägeloh-Mann4, Joachim Riethmüller4, Christopher Troedson5, Norio Sakai6, James Wu7, Douglas Kerr7, and Margaret Wasilewski7
1Medical Genetics Service, Hcpa/Ufrgs, Porto Alegre, RS, Brazil
2Neuropediatrics Unit, Bicêtre Hospital, Paris, France
3Department of Clinical Genetics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
4Department of Neuropediatrics, University Children's Hospital Tübingen, Tübingen, Germany
5The Children's Hospital at Westmead, Sydney, Australia
6Osaka University Hospital, Osaka, Japan
7Shire, Lexington, MA, USA
Metachromatic leukodystrophy (MLD) is an autosomal recessive disorder characterized by deficient activity of arylsulfatase A (ASA), resulting in sulfatide build-up in CNS and PNS cells. In late-infantile (LI)-MLD, neurodegenerative symptoms develop rapidly before premature death. This phase 1/2 multicenter, open-label, non-randomized study investigated the safety of intrathecally delivered recombinant human (rh) ASA in children with LI-MLD (NCT01510028). In cohort 4 (C4) patients received 100 mg rhASA every other week (EOW) produced using a revised manufacturing process (process B) to improve process efficiency and robustness. Results from C4 were compared with the previously reported initial 40-wk study in which cohorts C1, C2 and C3 received rhASA EOW at 10, 30 and 100 mg, respectively (process A). Eligibility criteria for all four cohorts was confirmed MLD diagnosis, first symptoms <30 mths and ambulatory (able to walk forward 10 steps with one hand held). In C1-C3 patients were aged <12 years and in C4 <8 years. In C4, Gross Motor Function Measure-88 (GMFM-88) was ≥40 at screening and ≥35 at baseline. Mean±SD enrollment age was 48.5±24.22 mths in C4 compared with 31.5 ± 11.50, 47.3 ± 20.23, and 52.2 ± 31.17 mths in C1, C2, and C3, respectively (n = 6 per cohort). Overall, ≥1 treatment emergent adverse event (TEAE) occurred in 24 patients (100%; 474 events), ≥1 rhASA-related TEAE occurred in 13 patients (54.2%; 50 events) and ≥1 serious TEAE occurred in 14 patients (58.3%; 44 events). There were no deaths or discontinuations due to study drug or device. Decline in motor function (LS mean ± SE change [baseline to wk 40] in GMFM-88 total scores) were –18.1 ± 9.14% and –19.5 ± 8.54% in C4 and C3 (100 mg doses) vs –31.9 ± 8.76% and –29.0 ± 8.58% in C1 and C2. Changes in N-acetylaspartate/creatine (NAA/Cr) metabolite ratios were evaluated by MRS (baseline to wk 40). In right parieto-occipital white matter, LS mean change was –0.1 ± 0.07 (n = 3) and 0.1 ± 0.05 (n = 5) in C4 and C3 vs –0.4 ± 0.08 (n = 2) and −0.2 ± 0.08 (n = 2) in C1 and C2. A trend towards stabilization of MRI-MLD severity score in C4 was seen, as described previously in C3. CSF sulfatides fell to the normal range by wk 28 in C3 and C4. In conclusion, intrathecal rhASA produced using process B was generally safe and well tolerated. The 100 mg cohorts had a lesser fall in motor function and positive effects in lowering CSF sulfatides and MRS (NAA/Cr) than the 10 or 30 mg cohorts. Shire funded this study and medical writing support.
700 - Disease Burden in 220 Latin American Female Patients With Fabry disease: A Fabry Registry Analysis
Ana Maria Martins1, Fernando Molt2, Fernando Suárez-Obando3, Gustavo Cabrera4, Roberta Lemay5, Juan M. Politei6
1University Federal of São Paulo, São Paulo, SP, Brazil
2Faculty of Medicine, Universidad Católica del Norte, Coquimbo, Chile
3Instituto de Genética Humana, Facultad de Medicina, Pontificia Universidad Javeriana, Bogotá, Colombia
4Cardiology Department, Del Viso Medical Center, Buenos Aires, Argentina
5Sanofi Genzyme, Cambridge, MA, USA
6Department of Neurology, Fundacion Para El Estudio de Enfermedades Neurometabolicas (Fesen), Buenos Aires, Argentina
Fabry disease is an X-linked, lysosomal storage disorder with remarkable genetic variability. Clinical expression in female patients is heterogeneous (from asymptomatic to severe presentations as seen in classic males) and is dependent on multiple factors including the type of mutation and the X-chromosome inactivation profile. We assessed the burden of Fabry disease in 220 Latin American female patients enrolled in the Fabry Registry (NCT00196742). Natural history data from females never treated with enzyme replacement therapy (ERT−) and females eventually treated with agalsidase beta (ERT+) were compared. Natural history data were obtained from 110 ERT- (median age 33 [range 1.9-83.6] years) and 110 ERT+ females (median age 46.7 [range 14.5-76.7] years) from Brazil (68, 78, respectively), Chile (21, 18), Argentina (14, 14), and Colombia (7, 0). Onset of first Fabry symptoms (any) occurred at median age 15.3 (ERT−) and 14.4 years (ERT+), and diagnosis at age 27.2 (ERT−) and 40.9 years (ERT+). ERT+ patients started ERT at a median age of 43.7 (range 12.9-73.7) years. Percentages of females reporting specific Fabry symptoms (% [median age at first report, years]) for ERT- and ERT+, respectively, were: abdominal pain: 23.2 [17.3], 45.8 [30.2], P = .01; diarrhea: 18.9 [21.2], 43.1 [25.7]; abnormal sweating: 68.7 [24.4], 89.1 [32.9]; peripheral pain: 69.6 [23.5], 96.7 [26.3]; acute pain crisis: 20.2 [20.4], 32.3 [31.4]; angiokeratoma: 21.1 [30.3], 32.2 [43.5]. Available data on symptom history (absence/presence) was more limited in the ERT+ group which hampers interpretation. There were no notable differences between the ERT- and ERT+ groups in the percentages of females with renal dysfunction or cardiac pathology (normal median values [averaged and most recent assessments]). Severe clinical events in ERT- and ERT+ groups included: cardiac: 0.9%, 4.5%, respectively; dialysis/transplant: 3.6%, 0.9%; stroke 0.9%, 2.7%; TIA 3.6%, 8.2%. In conclusion, female Fabry patients often experience symptom onset during adolescence but are at risk of delayed diagnosis well into adulthood. Renal and cardiac disease burden in ERT− and ERT+ females does not appear to be substantially different. In general, not all female patients are submitted to profound multidisciplinary clinical investigations as reflected by the limited data. All female patients should be regularly monitored and treatment guidelines should be adhered to. Sponsor Fabry Registry and abstract: Sanofi Genzyme.
701 - Healthcare Resource Utilization in Gaucher Disease in Israel
Dena Jaffe1, Natalie Flaks-Manov2, Becca Feldman2, Asaf Bachrach2, and Alain Joseph3
1Health Outcomes Practice, Kantar Health, Tel Aviv, Israel
2Clalit Health Services, Tel Aviv, Israel
3Shire, Zug, Switzerland
Gaucher disease (GD) is a rare autosomal recessive disorder caused by a mutation in the glucocerebrosidase gene. Relatively little is known about healthcare resource utilization (HCRU) for orphan diseases such as GD. The purpose of this study was to assess the burden to the healthcare system of a GD population over time using retrospective data from Clalit Health Services (Clalit), the largest of four managed care organizations in Israel. A retrospective cohort study was conducted to assess HCRU for registered Clalit patients in the following groups: patients with GD versus matched controls from the general population; patients with GD with and without bone events at baseline; patients with GD with and without hematological abnormalities or organomegaly at baseline. Patients with continuous enrollment in Clalit 1 year pre- and post-baseline (1/1/2008) were examined and followed for up to 8 years. The study included 2610 Clalit members: 435 patients (3276 person-years [PY]) with GD and 2175 controls (16 240 PY) without GD. Over an 8-year period, patients with GD had significantly higher HCRU per PY than those without GD, including increases relative to their matched controls of 23.9% for community visits, 12.3% for specialist visits, 37.9% for ambulatory admissions, 57.3% for imaging use, and 25.5% for hospital admissions (all P < .05). Within the GD population, 123 patients (897 PY) with a bone event at baseline had higher HCRU rates than those without (n = 269, 2049 PY), with increases of 41.6% for community visits, 24.1% for specialist visits, 39.0% for ambulatory admissions, and 51.5% for imaging use (all P < .05). GD patients with hematological abnormalities or organomegaly (n = 330, 2491 PY) at baseline had higher HCRU rates for ambulatory admissions (80.6%), imaging use (67.1%), and number of hospital admissions (200.3%; all P < .001) than those without these baseline symptoms, but similar rates for community and specialist visits and length of hospital stay. Overall, rates of HCRU were greater for patients with GD compared to the general population. High HCRU rates were seen for imaging use and ambulatory admissions among GD patients with a bone event, hematological abnormalities, or organomegaly at baseline, which are consistent with the monitoring requirements of the symptoms of GD, anemia, and thrombocytopenia. Further studies should examine outcomes related to the management of GD in at-risk populations.
702 - Bone Pathology in Type 1 Gaucher Disease: Results From a Systematic Literature Review
Hanna Rosenbaum1, Alain Joseph2, Christian Eichinger3, and Andrey Gurevich2
1Clalit Medical Consulting Center, Nazareth, Israel
2Shire, Zug, Switzerland
3Pharmagenesis London, London, United Kingdom
The occurrence of bone pathology remains a major clinical issue in patients with type 1 Gaucher disease (GD1). However, the relationship between bone disease and indirect markers of GD1 severity, and the role of bone pathology in overall disease burden, are unclear. A systematic review of the literature was undertaken to identify all publications on GD1 reporting on: (1) the relationship between indirect disease markers and bone pathology; (2) disease epidemiology and bone involvement; (3) the humanistic burden associated with bone disease; and (4) economic evaluations of treatments in relation to improving bone pathology. The searches identified 36 publications of interest: 24 papers reported results on the relationship between indirect disease markers and bone pathology; 4 reported on epidemiology; 8 on the humanistic burden; and 1 on economic evaluation. The occurrence of bone disease in GD1 was found to be related to specific variants in a number of genes, including glucocerebrosidase 1 (GBA1), bone morphogenetic protein 4 (BMP4), cytochrome P450 family 1 subfamily A member 1 (CYP1A1), interleukin 1-alpha (IL-1a), interleukin 1-beta (IL-1b), and interleukin 1 receptor antagonist (IL1RN). Several features of bone disease, including avascular necrosis (AVN) and glycolipid deposits in bone marrow, were found to be related to elevated chitotriosidase levels. Factors associated with an increased risk of developing bone disease in GD1 were older age at diagnosis, increased ferritin concentration, and decreased bone marrow fat fraction. Data on the prevalence of bone disease in GD1 were only available for AVN, with a reported incidence of 0.228 per 100 000 person-years in untreated individuals, versus 0.138 per 100 000 person-years in patients receiving enzyme replacement therapy (ERT). There were limited data on the economic burden of bone disease in GD1, but 1 study suggested higher annual healthcare costs relative to GD1 patients without bone disease. GD-related bone disease is associated with specific indirect markers of disease activity, and several of its features were found to be related to increased levels of chitotriosidase. Although there are limited data on the impact of treatment on bone disease, findings suggest that ERT is associated with a lower incidence of AVN.
703 - Evaluation of the Sleep Quality and Chronotype in Fabry Disease Patients
Julia Vallim, Fernanda Amaral, and Vânia D’Almeida
Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil
Fabry disease is a lysosomal storage disease characterized by a mutation in the GLA gene, located on X chromosome, whose main consequence is the enzymatic deficiency of alpha-galactosidase A and accumulation of globotriaosylceramide (Gb3). The storage of Gb3 is progressive and affects several tissues, especially the smooth muscle. In addition to the symptoms commonly reported by individuals with the disease, such as acroparesthesia and angiokeratomas, excessive daytime sleepiness is also often described by the patients. Alterations in sleep parameters have already been described in individuals with Mucopolysaccharidosis type III, another type of LSD, which suggests alteration of biological rhythmicity, since the propensity to sleep presents a strong circadian component, synchronized with the light/dark cycle. Therefore, the purpose of this study is to describe quality of sleep and the chronotype of individuals with Fabry Disease. To achieve this goal, 17 volunteers (7 men and 10 women)—median age of 43 years (17-62)—diagnosed by biochemical or molecular analysis with Fabry Disease regularly attended at the Center for Reference of Inborn Errors of Metabolism at UNIFESP were matched by sex and age with 16 healthy controls (6 men and 10 women), with a median age of 42.5 years (18-59), totaling 33 individuals. The volunteers answered three questionnaires: Epworth Sleepiness Scale, Morningness–eveningness questionnaire and Pittsburgh Sleep Quality Index. Among Fabry Disease patients, 52.9% presented a positive result for ESS, which corroborates previous data in the literature. Chronotype analysis showed that the control group presented an expected distribution of the profiles, replicating what occurs in the general population, where the most extreme chronotypes are less frequent and the intermediaries are more frequent. The Fabry group presented a different distribution, in which 53% of the subjects presented de morningness profile (71.4% males) against 18.8% in the control group (33.3% males). This result may be related to a different rhythm profile for individuals with Fabry Disease. Most individuals in both groups reported poor sleep quality (50% control group and 58.8% Fabry group). These results confirm data described in the literature and highlight some rhythmic differences in individuals with Fabry Disease. Further studies, using markers of biological rhythmicity, may be performed to add new information in these important biological aspects.
704 - Enzymatic Studies of Gaucher Disease in Colombia, A Compilation of the Results of Seventeen-Years of High-Risk Screening
Alfredo Uribe
Universidad de Los Andes, Bogotá, Colombia
705 - Renal Involvement in Fabry Disease
Asli İnci1, Gürsel Biberoğlu1, Ilyas Okur1, Özge Paşaoğlu2, Leyla Tümer1, Hatice Paşaoğlu2, and Fatih Ezgü1
1Division of Pediatric Metabolism and Nutrition, Gazi University School of Medicine, Ankara, Turkey
2Department of Medical Biochemistry, Gazi University School of Medicine, Ankara, Turkey
706 - Niemann-Pick C (NPC) Through Parent’s Eyes. Not Just a Case Report
Marcelo Minotti1, Elisa Aimoni1, and Marina Szlago2
1Niemann Pick Argentina, Caba, Argentina
2Consultorio de Errores Congénitos Del Metabolismo, Caba, Argentina
NPC is a progressive lysosomal storage disease associated with mutations in the NPC1 and the NPC2 genes. It is supposed to affect approximately1:150,000 people. Treatment became available in the last few years. Thanks to the generosity of her parents who share the lived experience in order to prevent their suffering from recurring in other families, we report the life story of ESM, a girl with NPC diagnosis. ESM was born on 1988. Just a few weeks before her 16th birthday she was discovered to have Niemann-Pick type C as the cause of her progressive deterioration. Up to 8 years of age she was a “normal” girl who interacted with peers, played, and practiced swimming, dancing, cycling and skating. Due to learning difficulties, poor attention span at school and writing worsening was referred to a psychologist. After a few months of therapy, the doctor evaluated that her problems were not psychological, so she was referred to a neurologist. ESM went through many medical studies and was diagnosed with ATAXIA of unknown etiology. She received no specific treatment. The symptoms progressed. Fine motor area and in the ocular movements began. She developed loss of the stability and balance, successively appeared difficulties in the speech, inconveniences in the swallowing of liquids, convulsive episodes and increasingly severe mandibular rigidity. As the new symptoms appeared, motor and balance were diminishing. Her menarche was at age 13, and always with irregular periods, her urine alternates between clear and odorless and cloudy with very strong odor. At that point, she was under vitamin E, high transaminases were detected and as there was no improvement, vitamin E was suspended. A new series of medical test studies did not give diagnostic confirmation. After almost 8 years of unsuccessful searches a skin biopsy was compatible with NPC, the genetic study confirmed the diagnosis. At the age of 16 she presented paralysis of the vertical and horizontal gaze, severe dysarthria, dystonic postures in both hands, severe postural instability, nasogastric tube for feeding. She assisted to rehabilitation treatments aiming to keep her occupied and happy. Her family and health caregivers tried at all times to improve her quality of life but unfortunately could not stop her progressive deterioration. We consider that the oral, write, photographic and videos registries of ESM's life will help physicians to improve early detection, understanding and treatment of NPC patients and families.
707 - Niemann-Pick Disease Type B: A Case Series of Brazilian Patients
Deivid Calebe de Souza, Thaliane Buranello, Rayana Maia, Charles Lourenço, and Marcela Lopes Almeida
Clinical Hospital of Ribeirão Preto, University of São Paulo, Riberão Preto, SP, Brazil
708 - LysoGb3 in Argentinean Fabry patients
Andrea Schenone, Silvia Beatriz Sokn, Dana Velasquez Rivas, Consuelo Durand, Martin Maccarone, Juan M. Politei, and Joaquin Frabasil
Laboratorio Chamoles, Buenos Aires, Argentina
Fabry disease (FD) is an X-linked lysosomal storage disorder caused by GLA mutations with an unknown incidence in Argentina. The α-galactosidase (α-Gal) deficiency results in the progressive accumulation of lysosomal substrates: leading to the storage of sphingolipids such as globotriaosylceramide (Gb3) and globotriaosylsphingosine (lyso-Gb3) in lysosomes of all cells in the body. Despite the pattern of inheritance, this disease may present a wide spectrum of clinical manifestations in both men and women. More than 800 mutations and some polymorphisms were detected in the GLA gene and, because of the disease heterogeneity, a useful biomarker is essential not only for treatment monitoring but also as a diagnostic tool when a new mutation or a variant of uncertain significance mutation is detected.
709 - Novel Mutations in a Case of a Peruvian Girl With Metachromatic Leukodystrophy
Hugo Hernán Abarca Barriga and Milana Trubnykova
Instituto Nacional de Salud Del Niño, Lima, Peru
We present the case of female patient from Piura (Northern region of Peru) with clinical and molecular diagnosis of metachromatic leukodystrophy. Infantile form of these autosomal recessive diseases is characterized by onset before 30 months of age, motor and mental deterioration, white matter lesions, and neuropathic changes in electromyography. The injury is caused by arylsulfatase (ARSA) deficiency leading for sulfatides deposit. Our patient had normal development before 1 year and 6 months when she began to regress. At the age of 2 years and 3 months she was evaluated by a geneticist. Her growth percentiles were normal except the cephalic perimeter (p2). She has diminished muscle tone, clonus, dystonia and increased osteotendinous reflexes. Her karyotype study had normal result (46, XX). MRI revealed increased white matter's signal. Her electromyographic study showed peripheral neuropathy. The ARSA activity was low by enzymatic study. WES (Whole exome sequencing) result was clinically relevant with variants with significant phenotype overlapping with this case: previously unreported heterozygous variant in the ARSA gene, c.1130_1132del (p.Phe377del), confirmed by Sanger sequencing and detected in the mother. It is a variant of uncertain significance (class 3) according to the recommendations of the Centogene and ACMG. Also, another unreported variant was found in heterozygosity: c.190T>G (p.Phe64Val), detected in the father. It is also a variant of uncertain significance (class 3). We are postulating these novel mutations as the cause for metachromatic leukodystrophy.
710 - Clinical, Biochemical, and Molecular Characterization of Patients With Gaucher Disease From Pará
Felipe Franco, Larissa Mendes, Luis Santana da Silva
UFPA, Belém, PA, Brazil
Gaucher disease (GD) is an autosomal recessive disease caused by β-glucosidase deficiency by mutations in the GBA gene, which encodes the enzyme. Chitotriosidase is a human chitinase secreted by active macrophages and used as a biomarker in the monitor of DG, the most common deposit lysosomal disease. The objective of this work was to genotype the GBA and CHIT1 genes in patients with GD from Pará State. Mutations in the GBA and CHIT1 genes were identified by PCR followed by direct sequencing. Three new previously described mutations in the GBA: S gene (-24) G (g.1872A> G), L (-25) S (g.1870T> C) and H419Y (g.6874C> T) and 15 mutations previously reported in other studies. The N370 S and RecNciI mutations were the most frequent, respectively, and then I489 T, the G377 S mutation was not found in our study. The genotyping of the CHIT1 gene revealed 3 (23%) patients homozygous for the allele with 24 bp, 3 (23%) heterozygous and 7 (54%) dominated homozygotes for the allele. In this way, it was possible to conclude that it is important to identify the spectra of mutations in the GBA gene to better understand the molecular basis of the disease. In relation to the CHIT1 gene, it is important to use other biochemical markers to monitor the disease, where the use of chitotriosidase is limited.
711 - Fabry Disease: A Way for Improving the Detection of Heterozygous Females in Dried Blood Spots and Analysis of Four New Genetic Variants Identified
Joaquin Frabasil, Consuelo Durand, Silvia Beatriz Sokn, Daniela Gaggioli, Patricia Carozza, and Andrea Schenone
Laboratorio Chamoles, Buenos Aires, Argentina
Fabry disease (FD) is an X-linked lysosomal disorder caused by mutations in the GLA gene, encoding the alpha-galactosidase A enzyme (AGAL). Heterozygous females (HF) for FD show a wide range of AGAL activity in vitro, from very low to normal values regardless of the type of sample analyzed: dried blood spots (DBS), plasma, leukocytes or fibroblasts. For this reason, the Gold Standard method for detection/diagnosis in women is GLA gene sequencing with large deletion/duplication analysis, an expensive and time-consuming method. HF may be asymptomatic although is likely that show some manifestations of disease, even these could be similar to those observed in men with classic FD. Detection is therefore essential for an early diagnosis and treatment, and for proper genetic counseling.
712 - Statistical Analysis of the Biochemical and Genetic Data in the Largest Global Fabry Cohort Reported to Present
Gabriela Elena Oprea1, Sabriana Eichler1, Claudia Cozma1, Tobias Böttcher1, Sabine Schröder1, Marius Iurascu1, Jan Lukas2, and Arndt Rolfs2
1Centogene Ag, Rostock, Germany
2Albrecht-Kossel-Institute, University of Rostock, Rostock, Germany
Fabry disease is an X-linked inherited lysosomal storage disease characterized by a deficient alpha-galactosidase caused by mutations in the GLA gene. Fabry diagnosis is performed in a high-throughput stepwise manner: (a.) males- enzymatic activity, lyso-Gb3 quantification, followed by GLA gene sequencing and, (b.) females- GLA gene sequencing followed by lyso-Gb3. In the development and validation of the enzymatic assay we observed that alpha-galactosidase determination in DBS alone is insufficient for a precise diagnosis of Fabry disease, both in females (ppv 78%) and males (ppv 94.2%) due to multiple variables: leukocyte count for different individuals; hematocrit level; sample handling, lyonization effect in females. To eliminate the differences between samples several optimizations were introduced: chemical blank for each sample, a standard curve measured in the presence of blood extract and the ratio alpha-galactosidase to another lysosomal enzyme (beta-glucuronidase). Lyso-Gb3 was measured using mass spectrometry (LC/MRM-MS) from DBS extract. Mild mutations or late onset patients present levels of lyso-Gb3 in normal range (21.59% of all Fabry male cases). However, by combining the data from three different biochemical parameters (Lyso-Gb3, alpha-galactosidase and ratio alpha-galactosidase / beta-glucuronidase) we can distinguish between the cohorts of normal controls, mild (or late onset) Fabry cases and affected Fabry cases. The biochemical diagnosis was confirmed in all cases by genetic analysis. We report here the screening of over 72 000 individuals that led to the identification of over 3000 affected individuals and over 900 carriers. We sequenced over 71 000 alleles, resulting in the identification of 480 unique pathogenic variants (40% of which never published before).
713 - Glucosylsphingosine (lyso-Gb1) Plays a Central Role in the Diagnosis and Correct Assessment of Disease Severity in Gaucher patients
Arndt Rolfs1, Anne-Katrin Giese1, Susanne Zielke1, Jan Lukas1, and Claudia Cozma2
1Albrecht-Kossel-Institute, University of Rostock, Rostock, Germany
2Centogene Ag, Rostock, Germany
Gaucher disease (GD) is an autosomal recessive, rare genetic disorder characterized by the deposition of glucocerebroside in cells of the macrophage-monocyte system. Although the disease is getting more apparent based on the available enzyme replacement treatment, the rate of proper early diagnosis of GD patients is still low. Standardized, simple and highly reproducible workflows for the diagnosis are crucial. We have developed and systematically validated a high-throughput workflow for the simple testing of GD patients: beta-glucocerebrosidase enzymatic activity, glycosylsphingosine (lyso-Gb1) quantification in DBS followed by GBA gene sequencing from the sample blood sample. Here, we report data from a screening study that compassed 4 years a screening of over 2,700 individuals that led to the identification of 873 Gaucher individuals (563 affected Gaucher patients and 310 carriers). Determination of lyso-Gb1 is performed by LC/MRM-MS. The lyso-Gb1 levels found Gaucher patients were clinically divided in: very mild (12ng/ml -25.0 ng/mL), mild (25.1 - 50 ng/mL), moderate (50.1 - 200 ng/mL) and severe (>200 ng/mL). Lyso-Gb1 was proven to have a sensitivity as well as specificity of 100%. We sequenced 2,257 alleles and identified 199 unique pathogenic GBA variants. From thee unique variants, 35% were not reported in literature up to now. The clinical severity of the mutations and their location can be correlated with the lyso-Gb1 concentration in the homozygous cases, e.g. c.1295G>T is correlated with mild lyso-Gb1 values while c.1060G>A and c.518C>A with extremely high lyso-Gb1 values (> 600 ng/mL). The most common mutations were c.1226A>G (30.1%) and c.1448T>C (24.7%). Lyso-Gb1 for c.1226A>G can vary from very mild to moderate. c.1448T>C is a severe mutation correlating to a massive increase of lyso-Gb1 up to 1,250 ng/mL. Lyso-Gb1 concentrations in blood can be used for the easy and early diagnosis of Gaucher patients and for treatment monitoring.
714 - The Increased Glucosylsphingosine Level in Patients With Parkinson’s Disease With GBA Mutations
Sophia Pchelina1, A Emelyanov1, Galina Baydakova2, K Senkevich1, M Nikolaev1, I Miliukhina1, and Ekaterina Zacharova2
1Petersburg Nuclear Physics Institute, First Pavlov State Medical University of St. Petersburg, Saint-Petersburg, Russia
2Federal State Budgetary Institution «Research Centre for Medical Genetics», Moscow, Russia
715 - The Clinical and Demographic Features of 23 Niemann-Pick Type A/B Patients From South and Southeast Parts of Turkey
Neslihan Mungan1, Deniz Kor2, Berna Seker Yilmaz1, Fatma Derya Bulut1, and Sebile Kilavuz1
1Div Ped Metab Dis, Uni Cukurova, Adana, Turkey
2Div Ped Metab Dis, Adana Numune Edu Res Hosp, Adana, Turkey
716 - Niemann Pick Disease Type B: Identification of a New Mutation
William Márquez1,4, Adriana Ramírez2, Sonia Restrepo3,4, and Yaqueline Ladino5
1Departamento de Enfermedades metabólicas. Fundación Homi. Hospital de la Misericordia. Bogotá, D.C., Colombia
2Laboratorio clínico. Clínica Colsanitas. Bogotá, D.C., Colombia
3Departamento de Neumología. Fundación Homi. Hospital de la Misericordia. Bogotá, D.C., Colombia
4Departamento de Pediatría, facultad de Medicina. Universidad Nacional de Colombia. Bogotá, D.C., Colombia
5Departamento de Genética. Fundación Homi. Hospital de la Misericordia. Bogotá, D.C., Colombia
717 - Determination of Lysosphingolipids by LC-MS/MS in Lysosomal Storage Diseases
Federica Deodato, Sara Boenzi, Roberta Taurisano, and Carlo Dionisi Vici
Bambino Gesù Children’s Hospital, Rome, Italy
718 - Determination of Oxysterol for NPC Screening in Patients With Cholestasis Syndrome
Tatiana Proshlyakova1, Anna Degtyareva2, Galina Baydakova1, Elena Kamenets1, Yulia Itkis1, and Ekaterina Zacharova1
1Fsbi «Research Centre for Medical Genetics», Moscow, Russia
2Research Center for Obstetrics, Gynecology and Perinatology, Moscow, Russia
719 - Acid Ceramidase: One Gene, One Enzyme, and Multiple Phenotypes
Edward Schuchman
Icahn School of Medicine at Mount Sinai, New York, USA
Acid ceramidase (AC) is the lysosomal enzyme required to hydrolyze ceramide into sphingosine and free fatty acids. Mutations in the acid ceramidase gene (ASAH1) result in two rare, recessively inherited disorders, Farber Disease (FD; OMIM #228000) and Spinal Muscular Atrophy with Progressive Myoclonic Epilepsy (SMA-PME; OMIM #159950). The ASAH1 cDNA and gene have been isolated, and recombinant human AC (rhAC) has been produced and characterized from Chinese hamster ovary cells. Proof-of-concept enzyme replacement therapy (ERT) studies also have been carried out in AC deficient mice and FD cells, and “first-in-man” clinical trials in FD patients are currently been planned. Due its central role regulating ceramide and other sphingolipid metabolism, including sphingosine and sphingosine-1-phosphate, AC is a key rheostat controlling the balance between cell death and survival, and abnormal AC expression has been described in numerous other diseases, including cancer, age-related dementia, diabetes, blindness, and lung diseases such as COPD. Of particular note, AC deficiency occurs in respiratory epithelial cells of patients and mice with Cystic Fibrosis (CF), and inhalation of rhAC into CF mice reduces inflammation and prevents or reverses acute infection with Pseudomonas aeruginosa. We have also shown that rhAC can be used to enhance the outcome of in vitro fertilization procedures by promoting the survival of unfertilized oocytes and preimplanation embryos. It also enhances the survival of primary chondrocytes and induces chondrogenesis of mesenchymal stem cells, and can be used to improve the outcome of cell-based cartilage repair procedures as well. This presentation will provide an overview of AC biology and its involvement in various diseases.
720 - A cross-sectional natural history study design to address the lack of clinical data on acid ceramidase deficiency presenting as Farber disease
Dustin Tetzl1, Edward Schuchman2, and Alexander Solyom3
1Enzyvant, New York, NY, USA
2Icahn School of Medicine at Mt. Sinai, New York, NY, USA
3Enzyvant, Basel, Switzerland
721 - A Qualitative Research Study Documenting the Clinical Impact of Symptoms in a Diverse Population of Patients and Caregivers With Acid Ceramidase Deficiency (Farber Disease)
Dustin Tetzl1, Karin Coyne2, Brendan Johnson3, Alexander Solyom4, and Karoline Ehlert5
1Enzyvant, New York, USA
2Evidera, Bethesda, MD, USA
3Roivant Sciences, Durham, NC, USA
4Enzyvant, Basel, Switzerland
5University Medical Center Greifswald, Greifswald, Germany
722 - Niemann Pick Type C Diagnostic Methods and Survey: National Intervention-Free INSPECT Registration Study Protocol Presentation
Didem Ardicli1, Neslihan Mungan2, Mahmut Coker3, Leyla Tumer4, Mehmet Gunduz5, Pinar Topaloğlu Tektürk6, Turgay Coşkun7, Miraç Yildirim1, and Meral Topcu1
1Hacettepe University, Department of Pediatric Neurology, Ankara, Turkey
2Cukurova University, Department of Pediatric Endocrinology, Adana, Turkey
3Ege University, Department of Pediatric Nutrition and Metabolism, İzmir, Turkey
4Gazi University, Department of Pediatric Nutrition and Metabolism, Ankara, Turkey
5Ankara Child’s Health and Diseases Research Hospital, Department of Pediatric Metabolism, Ankara, Turkey
6Istanbul University, Department of Neurology, Istanbul, Turkey
7Hacettepe University, Department of Pediatric Nutrition and Metabolism, Ankara, Turkey
723 - Fabry Disease’s Clinical Picture in Brazilian Dialysis Centers
Marcia Ribeiro1, Marcelo Coutinho2, Luisa Baptista2, Júlio Araújo3, Túlio Santos4, Oswaldo Neto5, Jorge Lopez6, and Paula Dias Maia1
1Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
2Genetics Service, Campos dos Goytacazes, Campos dos Goytacazes, RJ, Brazil
3Computer Institute, Fluminense Federal University, Campos dos Goytacazes, RJ, Brazil
4Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
5Ribeirão Preto Medical School, São Paulo University, Ribeirão Preto, SP, Brazil
6Edmundo Vasconcelos Hospitalar Complex, São Paulo, SP, Brazil
Fabry disease (FD) is an X-linked disease with an estimated incidence of 1:40 000–170 000 and is usually marked by chronic pain, angiokeratomas, hypohidrosis, heat/cold intolerance, corneal abnormalities, renal injury, stroke, and cardiac complications. Complications may become life-threatening, including renal failure. Our objective was to verify the prevalence of clinical signals/symptoms and of some comorbidities in FD patients. A cross-sectional study, approved by the Research Ethics Committee of Campos Medical School, was performed in Brazilian dialysis centers from July 2013 to July 2015. Each patient signed a consent form. The sample consisted of FD-suspected patients, placed into two groups: positive FD patients (FD+), (diagnosed by biochemical and/or molecular analysis) and negative FD patients (FD−), (excluded by biochemical and/or molecular analysis). The sample was selected by a database called DataGenno Interactive Research®: first, a clinical questionnaire was created based on FD signals/symptoms and comorbidities; the obtained data were entered in the database in order to be sorted into the groups above. The variables were: cornea verticillata, abdominal pain after food ingestion, angiokeratoma, hearing problems, decreased/absent sweating, numbness sensation, pain crises, burning sensation, exercise intolerance, cold/heat intolerance, recurrent fever, cerebrovascular disease, palpitation/precordialgia, obesity, diabetes mellitus (DM), and high blood pressure (HBP). Renal failure was not considered because it was present in all patients. A total of 9081 patients were select from 35,201 patients from dialysis centers; 130 were FD+ and 8951, FD-. The average age was 43.93 (±16.53) and 45.86 (±14.07) for FD+ and FD−, respectively. Females were more prevalent than males in FD+ comparing to FD− (P < .001). More prevalent signs and symptoms in FD+ were: palpitation/precordialgia (39.23%) followed by decreased/absent sweating, numbness sensation, cold/heat intolerance (34.61% each), pain crises (33.84%), cerebrovascular diseases (27.69%) and burning sensation (21.53%), among others. Angiokeratoma was present in less percentage (12.03%) and the comparison between FD+ and FD− patients was significant (P < .001). HBP occurred in 37.69%, DM in 8.46% and obesity in 2.30% of FD+, percentages significantly lower than in FD−. FD is clinically heterogeneous and probably under diagnosed; Datagenno may be a valuable tool to improve FD diagnosis
724 - Natural History of Early-Infantile Krabbe Disease
Nicholas Bascou, Maria Beltran, Michele Poe, and Maria Escolar
Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
725 - Correlation of Lyso-GB3 Level and GLA Mutations in Patients From Screening Cohort Among Dialysis Centers in Russian Federation
Kirill Savost’Anov, Leyla Namazova-Baranova, Alexander Pushkov, Natalya Mazanova, Anton Khrapov, and Evgeny Pen’Kov
National Scientific and Practical Center of Children’s Health of the Ministry of Health of The Rf, Moscow, Russia
726 - Acute Neuronopathic Gaucher Disease (Gaucher type 2) in Two Turkish Infants
Mustafa Kiliç
Sami Ulus Children Hosp., Metabolism Unit, Ankara, Turkey
727 - Limited Benefits of Presymptomatic Cord Blood Transplantation in Neurovisceral Acid Sphingomyelinase Deficiency (ASMD) Intermediate Type
Samia Pichard1, Oriane Mercati1, Marie Ouachée2, Roseline Froissart3, Odile Fenneteau4, Bastien Roche1, Monique Elmaleh5, Yves Bertrand6, Hélène Ogier de Baulny1, Marie Thérèse Vanier3, and Manuel Schiff1
1Reference Centre for Inborn Errors of Metabolism, Robert Debré University Hospital, Paris, France
2Department of Hematology, Robert Debré University Hospital, Paris, France
3Laboratory for Inborn Errors of Metabolism, Cbpe, East Hospital, Hospices Civils de Lyon, Bron, France
4Department of Biological Haematology, Robert Debré University Hospital, Paris, France
5Departement of Pediatric Imaging, Robert Debré University Hospital, Paris, France
6Department of Child Haematology and Oncology, Ihop University Hospital, Lyon, France
728 - Skeletal Manifestations in Algerian Children With Gaucher disease
Amel Hadji Lehtihet1, Samira Lehtihet2, Lamine Sadeg1, Rania Seddik1, Samia Sokhal1, and Rachida Boukari1
1University of Medicine, Algiers, Algeria
2University of Medicine Blida, Douera, Algeria
Enzyme replacement therapy (ERT) is effective for the treatment of the systemic manifestations of Gaucher disease (GD) and can have a significant impact on skeletal manifestations. Bone disease in children is a major cause for concern as it puts them at risk of developing irreversible and debilitating bone complications and interferes with normal growth and achievement of optimal bone mass during a critical period of growth.
729 - Natural History of Metachromatic leukodystrophy
Nicholas Bascou, Michele Poe, and Maria Escolar
Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
Metachromatic leukodystrophy (MLD) is a rare demyelinating disorder caused by deficient activity of arylsulfatase A, a lysosomal enzyme involved in the degradation of 3’-O-sulphogalactosylceramide (sulfatide). MLD is divided into subtypes based on age of onset, with each subtype having a variant disease course. The purpose of this prospective study was to investigate disease progression in each subtype in order to identify early clinical symptoms. 104 MLD patients with late-infantile (LI), early-juvenile (EJ), late juvenile (LJ), or adult onset were evaluated from 2000 to 2017. Assessments included physical exams, neurodevelopment evaluations (cognitive, motor, expressive/receptive language, adaptive behavior), neuroimaging and neurophysiologic tests. LI onset was most prevalent (60.57%), followed by EJ (21.15%), LJ (13.46%), and adult onset (4.81%). Median age of onset in each cohort was 16, 50.5, 76, and 168 months, respectively, with a median delay of 11, 16, 23, and 108 months between onset and diagnosis. Initial LI symptoms involved delayed achievement of GM milestones (46.03%), abnormal gait (28.57%), and GM regression (20.60%). Similar initial symptoms were seen for EJ patients, although some cases involved impairment of fine motor skills and language acquisition. The majority of individuals with LJ onset displayed cognitive deficiencies, with 50% of children initially presenting with memory/attention/learning difficulties and changes in personality (21.43%). In the adult group, the onset had greater variability and entailed changes in personality and psychiatric disturbances. Abnormal NCV studies were present for 96% of LI patients, with the one normal study in an asymptomatic 8-month-old. Mixed results were seen in EJ and LJ NCVs; only 25% of adult NCVs were abnormal. Periventricular T2 white matter hyperintensities were the most common MRI finding in all cohorts, although cerebral hyperintensities became more common as age of onset increased. This is the largest longitudinal study of MLD performed at the same site using a standardized evaluation. The results show the predominantly early involvement of peripheral nerves affecting motor skills, with a predominance of cognitive and behavioral symptoms emerging as patients get older. Further evaluation of the neurophysiological studies and brain MRIs will be important for understanding the impact of these abnormalities on disease progression.
730 - Natural history of late-infantile Krabbe disease
Nicholas Bascou, Anthony Derenzo, Michele Poe, and Maria Escolar
Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
731 - Nieman-Pick C1 Disease: A Novel Mutation in an Algerian Child
Amel Hadji Lehtihet, Nacima Assami, Samia Sokhal, Fahd Eddaïkra, and Rachida Boukari
University of Medicine, Algiers, Algeria
Niemann-Pick disease type C is a neurodegenerative disorder caused by mutations in NPC1 and NPC2 genes. NP-C disease is very heterogeneous in its presentation. It has a variable age of onset, and a range of visceral, neurological, and psychiatric clinical features can arise at different disease stages and progress at different rates.
732 - Improvements in Brain Development Following Hematopoietic Stem-Cell Transplantation in Krabbe disease
Jue Wu, Maria Escolar, and Michele Poe
Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
733 - Expression of Acid Sphingomyelinase in Human Saliva and its Diagnostic Importance in Niemann-Pick Disease Type b
Lidia Dora Martínez1, Natalia Guzman2, Alicia Giner-Ayala3, Celia Angaroni1, and Raquel Dodelson de Kremer1
1Centro de Estudio de las Metabolopatías Congénitas, Cemeco. Facultad de Ciencias Médicas. Unc., Córdoba, Argentina
2Biología Celular, Cátedra “B”. Facultad de Odontología, Universidad Nacional de Córdoba, Córdoba, Argentina
3Centro de Estudio de Las Metabolopatías Congénitas, Cemeco. Facultad de Ciencias Médicas. Unc., Cördoba, Argentina
734 - Psychosine, A Marker of Krabbe Phenotype and Treatment
Maria Escolar1, Michele Poe1, Bridget Kiely1, Emily Shawgo1, Joseph Orsini2, Xinying Hong3, Michael Gelb3, and Dietrich Matern4
1Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
2New York Department of Health, Albany, NY, USA
3University of Washington, Seattle, WA, USA
4Mayo Clinic, Rochester, MN, USA
Newborn screening (NBS) for Krabbe disease, a rare neurodegenerative disorder caused by deficient galactocerebrosidase (GALC) enzyme activity, has recently been implemented in a number of US states. However, the spectrum of phenotypic manifestations associated with deficient GALC activity complicates the management of screen-positive newborns and underscores the need to identify clinically relevant biomarkers. Earlier studies with a small number of patients identified psychosine, a substrate of the GALC enzyme, as a potential biomarker for Krabbe disease. In this study, we provide, for the first time, longitudinal data on dried blood spot (DBS) psychosine concentrations in different Krabbe disease phenotypes for both untreated patients and those treated with hematopoietic stem cell transplantation (HSCT). From 2010 to 2016, DBS samples were prospectively collected from 69 patients with a confirmed diagnosis of KD, four sibling carriers, and two asymptomatic NBS-positive patients during clinical evaluations at the Program for the Study of Neurodevelopment in Rare Disorders (NDRD). Based on the age at which symptoms appeared, patients with KD were classified as having EIKD (0-6 months at onset), LIKD (6-48 months at onset), or juvenile-onset KD (4-18 years at onset). These samples were tested for psychosine levels and plotted by age, subgrouping by disease onset and transplant status.
735 - Next-Generation Versus Sanger Sequencing: Validation of NGS for Genotyping CHIT1 Alterations in Gaucher Disease Patients
Raíssa Caldeira1, Bianca Heineck1, Suélen Basgalupp2, Fernanda Sperb-Ludwig1, Filippo Vairo3, Marina Siebert4, and Ida V D Schwartz3
1Postgraduate Program in Genetics and Molecular Biology, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
2Postgraduate Program in Medical Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
3Medical Genetics Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
4Molecular and Protein Analysis Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
Gaucher disease (GD) is an inborn error of metabolism of sphingolipids caused by the beta-glucocerebrosidase deficiency which leads to substrate accumulation within the lysosomes of reticuloendothelial cells. GD can be classified in type I—a mild form, mainly presenting visceral enlargement; and types II and III—presenting acute and chronic neurological impairment, respectively. The specific treatment options for GD are enzyme replacement or substrate reduction therapy. To monitor the treatment efficacy in patients, several biomarkers can be measured. Chitotriosidase (chito) is a macrophage-produced enzyme encoded by the CHIT1 gene. It can be increased in up to 1000-fold the normal level in untreated GD patients, decreasing over treatment. There are eight CHIT1 polymorphisms known to impair chito activity reported at the Human Gene Mutation Database (HGMD). Thus, it is important to stratify the patients according to CHIT1 genotype for a better treatment follow-up. The aim of the study was to validate a next generation sequencing (NGS) method for CHIT1 analysis in the Reference Center for GD at the Hospital de Clínicas de Porto Alegre. DNA samples from 21 GD patients were amplified by multiplex PCR using an Ion Ampliseq Panel™ and sequenced by Ion Torrent PGM machine. The results were analyzed using Ion Reporter v.5.2 software and compared to results obtained from conventional PCR followed by Sanger sequencing using ABI 3500 Genetic Analyzer. The variants found were c.304G>A (p.G102 S), classified as pathogenic; c.1325C>G (p.A442G) and c.1049_1072dup24—both likely benign. The alleles frequencies found within the sample population by Sanger sequencing were 0.309, 0.095, and 0.142; by NGS were 0.309, 0.119 and 0.142, and in the 1000genomes database are 0.290, 0.109 and 0.289, respectively. The NGS results had a 95% consistency rate when comparing to Sanger sequencing (20 out of 21). In the one discordant case, NGS was able to detect all three variants in heterozygosis against two (p.G102 S and dup24) found by Sanger. It may be explained due to NGS greater sensitivity to detect low frequency variants (<10%). Although a few discrepancies might occur, NGS showed to be a reliable and promising high throughput method for genotyping CHIT1.
736 - Tay-Sachs Disease, p.Arg137* and p.Arg178His Variants
Fabrício Maciel Soares1, Ana Paula de Castro Ahid2, Patrícia da Silva Sousa3, and Maria Juliana Rodovalho Doriqui3
1Federal University of Maranhão, São Luís, MA, Brazil
2Universidade Ceuma, São Luís, MA, Brazil
3Hospital Infantil Dr. Juvêncio Matos, São Luís, MA, Brazil
U) 21. Lysosomal Disorders: Others (737 to 777)
737 - Molecular Insight, Identification of Novel Genotype, Establishment of Genotype-Phenotype Correlation, and Preparation of Mutational Dataset for Metachromatic Leukodystrophy of Indian Ethnic Population
Avinash Lomash
Genetics & Metabolic Lab, Genetics Division, Department of Pediatrics, Maulana Azad Medical College, New Delhi, India
738 - Gastrointestinal Endoscopy in Disease Monitoring
Sandra Obikawa Kyosen1, Stephan Geocze2, Marcelo Yamamoto1, Carmen Mendes1, Carolina Aranda1, Marco Curiati1, Maret Rand1, Patricia Feliciano1, and Ana Maria Martins1
1Centro de Referência Em Erros Inatos do Metabolismo, Universidade Federal de São Paulo, São Paulo, SP, Brazil
2Centro de Endoscopia Digestiva e Respiatoria, Hospital São Paulo, Universidade Federal de São Paulo, São Paulo, SP, Brazil
739 - Genotype-Phenotype Parameters of Mucolipidosis of II and III A Types in Russian Patients
Alla Semyachkina1, Elena Voskoboeva2, Tatiana Bookina2, Anna Bookina2, Ekaterina Nikolaeva1, Ilya Dantsev1, Malvina Kharabadze1, and Yulia Davydova1
1Research and Clinical Institute of Pediatrics Named After Yuri Veltischev of the Pirogov University, Moscow, Russia
2Research Centre for Medical Genetics of the Russian Academy of Sciences, Moscow, Russia
740 - Characterization of Patients With Galactosialidosis and Sialidosis Type 1
Tricia Cimms1, Qais Abu Ali1, Sarah Kilgariff2, Chloe Johnson2, Rob Arbuckle2, Betsy Malkus1, Andrea Schatz1, and Tine Haller1
1Ultragenyx Pharmaceutical, Inc., Novato, CA, USA
2Adelphi Values, Cheshire, United Kingdom
Galactosialidosis (GS) is a lysosomal disorder characterized by a combined deficiency of glycoprotein-specific N-acetyl-α-neuraminidase and β-galactosidase, secondary to a defect in protective protein/cathepsin A (PPCA). Three subtypes of GS have been described: early infantile or severe neuropathic, late infantile or attenuated, and juvenile/adult or neuropathic. Sialidosis, also a lysosomal disorder, is characterized by a neuraminidase deficiency and is recognized in two forms: Type 1 (ST-1) usually presents in the second decade of life and can have neurological involvement; Type 2 is more severe with an earlier onset. Both GS and ST-1 are possible therapeutic indications for a novel recombinant human enzyme PPCA.
741 - Efficacy of Pegunigalsidase Alfa (PRX-102), A Chemically Modified Plant Cell Culture Expressed Human α-Galactosidase-A Enzyme, on Neuropathic Phenotypes in a Mouse Model of Fabry Disease
Jin-Song Shen1, Siamak Jabbarzadeh-Tabrizi1, Deborah L. Berry2, Tali Kizhner3, Yoseph Shaaltiel3, and Raphael Schiffmann1
1Institute of Metabolic Disease, Baylor Research Institute, Dallas, TX, USA
2Georgetown University Medical Center, Washington, DC, USA
3Protalix, Carmiel, Israel
Fabry disease (FD) is an X-linked glycosphingolipidosis caused by deficient activity of α-galactosidase A (α-gal A); it exhibits a variety of clinical manifestations, of which small-fiber neuropathy is a key feature of the disease. Enzyme replacement therapy (ERT) is currently the standard care for Fabry patients (agalsidase alfa and beta). Pegunigalsidase alfa, a novel PEGylated, chemically modified α-gal A, shows a superior stability and markedly increased half-life in the circulation and enhanced mouse tissues delivery compared to approved ERTs.
742 - Cholestane-3β,5α,6β-triol and Chitotriosidase Combined Analysis: Potential Use for Niemann-Pick Type C Diagnosis and Screening
Graziela Ribas, Jurema de Mari, Marion Deon, Maria Luiza Saraiva-Pereira, Fernanda Timm, Rejane Kessler, Franciele Trapp, Kristiane Michelin, Maira Burin, Carmen Regla Vargas, and Roberto Giugliani
Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
Niemann-Pick type C (NPC) is a severe genetic disorder, mainly characterized by neurological dysfunction and liver damage. It is caused by mutations in the genes NPC1 or NPC2, leading to an abnormal accumulation of cholesterol within cellular lysosomes. Diagnosis is usually performed by the demonstration of cholesterol excess in fibroblasts (Filipin test) or by molecular analysis. However, considering the great benefits of the early treatment, new biomarkers able to screen NPC patients with high sensitivity and specificity have been stablished. With this purpose, we investigated the potential use of the combined analysis of cholestane-3 β,5 α,6 β-triol (triol) and the chitotriosidase (CT) activity for diagnosis, screening and monitoring of NPC patients. The levels of triol were investigated by LC/MS in plasma samples of 122 untreated individuals with clinical suspicion of NPC and also in 5 patients with previous diagnosis of NPC under treatment with miglustat. We detected 16 subjects with abnormal concentrations of triol (higher than 100 ng/mL), most of them also presented increased CT activity and 11 were confirmed as NPC by the Filipin test. Two patients of this group presented inconclusive results in the Filipin test, being one eventually diagnosed as NPC by molecular investigation and the other eventually diagnosed as Niemann-Pick type A or B (NPA/B) by the low acid sphingomyelinase (ASM) activity presented. Three patients with high triol concentrations had a negative result in the Filipin test, as well as low ASM activity, being diagnosed as NPA/B. On the other hand, triol concentrations were normal in NPC patients treated with miglustat, although CT activity in these individuals remained altered. In the 106 patients with normal triol concentrations (lower than 100 ng/mL), most presented a normal activity of CT. No patient of this group had a positive Filipin test and the few patients with inconclusive Filipin test did not present pathogenic mutations in the NPC1 or NPC2 genes. In conclusion, our data demonstrated that the combined analysis of triol and CT is a promising approach not only to help the diagnosis and monitoring of NPC patients, but also to enable the screening of these patients before the disease worsening.
743 - Detection of Lysosomal Storage Diseases by a Multiplex Tandem Mass Spectrometry Method
Carmen Regla Vargas, Graziela Ribas, Jurema de Mari, Gabriel Civallero, Maira Burin, and Roberto Giugliani
Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
Lysosomal storage diseases (LSDs) comprises a heterogeneous group of more than 50 genetic disorders with a combined incidence of 1 per 7700 live births. They are characterized by progressive accumulation of macromolecular substrates within lysosomes, leading to cellular dysfunction, which may affect both somatic organs and the central nervous system. Since substrate accumulation and its tissue distribution can be variable even among patients with identical genotypes, the symptoms of LSDs are not always recognized early in life. In this context, interest in screening methods for LSDs has increased in the last years, especially because early diagnosis is essential to prevent the complications of these diseases, and tandem mass spectrometry (MS/MS) has been appointed as the most appropriated methodology for this purpose. So, in this work we aimed to evaluate the performance of MS/MS for detection of six LSDs (Niemann-Pick A/B, Krabbe, Gaucher, Fabry, Pompe, and MPS-I diseases). Standard curves and quality control dried blood spots were assayed to evaluate the precision, linearity and accuracy of the method. Samples from 150 controls, grouped according to age, and from 59 patients with previous diagnosis of LSDs were subjected to the measurement of acid sphingomyelinase, galactocerebrosidase, β-glucocerebrosidase, α-galactosidase, α-glucosidase, and α-L-iduronidase. The results obtained from calibration curves demonstrated good linearity and accuracy and the intra- and interassay precisions varied from 1.17% to 11.60% and 5.39% to 31.24%, respectively. For most enzymes, the activities in controls were higher in newborns compared to children and adults. As expected, all affected patients were well discriminated, presenting activities significantly lower compared to all control subjects. In conclusion, our results showed that MS/MS is a promising methodology to screen LSDs, being extremely useful for guiding other biochemical or molecular investigations necessary to conclude the diagnosis.
744 - Evolving Observational Registries: An Evidence Based Approach to Understanding Data Availability in the Sanofi Genzyme Rare Disease Registries
Danielle Dong1, Julie Batista1, Katherine Belk2, Marta Cizmarik1, Cinde Clatterbuck1, Kathleen Faherty1, Hugh Findlay1, Jean Foster1, Anja Glaetzer3, Daniel Gruskin1, Bill Hartman2, Rafael Ioschpe1, Betsy Loisel1, Zarla Ludin2, Linda Massey1, Virginia Mcmillin4, Kristin Moy1, Virginia O’Neil1, Susan Sparks1, and Christiane Denzel1
1Sanofi Genzyme, Cambridge, MA, USA
2Essential Design, Boston, MA, USA
3Sanofi Pasteur, Singapore, Singapore
4Pra Health Sciences, Raleigh, NC, USA
The Sanofi Genzyme-sponsored Rare Disease Registries (Gaucher [ClinicalTrials.gov NCT00358943], Fabry [ClinicalTrials.gov NCT00196742], Pompe [ClinicalTrials.gov NCT00231400], and MPS I [ClinicalTrials.gov NCT00144794]) represent the largest global, observational databases for these lysosomal storage diseases. Since the inception of the first Registry in 1991, Registry data have been utilized to advance disease understanding, ensure access to therapies, and optimize patient outcomes. Operational support provided to Registry sites ensures operational success with compliance and data integrity. To further guide the evolution of the Registries in a systematic, evidence-based manner, a project was undertaken to identify barriers to data entry and to understand the quantity of data available for analysis. On-line surveys focused on data entry barriers were distributed to all active Registry site users; 151 surveys were completed (19%) within 4 weeks. Survey results informed the development of a qualitative interview guide. Interviews were conducted with 27 Registry participants from 12 countries. To evaluate the quantity of data available for analysis, a cross-Registry subset of 97 parameters was evaluated along the stepwise progression of data classified as “entered” to “usable.” Data entry barriers identified include the absence of data when assessments are not performed, limited time and resources to enter data, challenges obtaining medical records, and difficulties matching data from medical records to the Case Report Forms. The percentage of patients with usable data for any one of the 97 parameters ranged from 2% to 93%. A decline in quantity from data classified as “entered” to “usable” was observed for both untreated and treated patients; however, treated patients had a consistently larger amount of usable data. These results illustrate the determinants of data in the Registries and provide a roadmap to inform changes in what and how data are collected. These data will complement continual efforts aimed at evolving the Registries so they continue to meet current and future scientific research needs.
745 - Natural History of Two Adult LALD Siblings: 25 Years of Follow-Up
M Teresa Cardoso1, P Chaves1, M Vasconcelos2, Joanne Lopes3, E Rodrigues4, T Campos4, M Bourbon5, A Guerra6, and E Leão Teles4
1Reference Centre Inherited Metabolic Diseases, Int Med Depart, Chs João, Porto, Portugal
2Cardiology Depart, Chs João, Porto, Portugal
3Surgical Pathology Depart, Chs João, Porto, Portugal
4Reference Centre Inherited Metabolic Diseases, Paed Depart, Chs João, Porto, Portugal
5Biopathology Center, Insa, Lisboa, Portugal
6Paediatric Nutrition Unit, Paediatric Department, Chs João, Porto, Portugal
746 - Follow-Up Results of Fabry Disease Patients in Relation With Risk Perception
Selda Bülbül, Osman Dursun, and Sevda Akkuş
Kirikkale University Medical School, Ankara, Turkey
747 - A Possible Link Between Urinary Gb3, Lipid Peroxidation, and Nitrosative Stress in Fabry Patients Before and During Long-Term ERT
Giovana Brondani Biancini1, Tatiane Hammerschimitt2, Carlos Eduardo Diaz Jacques3, Heryk Motta de Souza2, Bruna Donida1, Marion Deon2, Hans German2, Charles Lourenço4, Camila Delgado3, Roberto Giugliani5, and Carmen Regla Vargas1
1Programa de Pós-Graduação Em Ciências Biológicas: Bioquímica, Ufrgs, Porto Alegre, RS, Brazil
2Serviço de Genética Médica, Hcpa, Porto Alegre, RS, Brazil
3Programa de Pós-Graduação Em Ciências Farmacêuticas, Ufrgs, Porto Alegre, RS, Brazil
4Departamento de Neurociências e Ciências do Comportamento, Usp, Ribeirão Preto, RS, Brazil
5Departamento de Genética, Ufrgs, Porto Alegre, RS, Brazil
Fabry disease (FD) is caused by deficient activity of the lysosomal enzyme α-galactosidase A. Its substrates, mainly globotriaosylceramide (Gb3), accumulate and seem to induce the pathophysiological findings of FD. Elucidating the underlying mechanisms in FD pathophysiology is essential to the development of additional therapeutic strategies, once the available one, enzyme replacement therapy (ERT), is not completely efficient on preventing disease progress. Based on previous findings of higher lipid peroxidation during short-term ERT, the already described relationship between nitrosative stress and vasculopathy, and the induction of pathophysiology mechanisms by Gb3, the objective of this study was to investigate lipid peroxidation, nitrosative stress and Gb3 in Fabry patients at diagnosis and to compare it with patients during long-term ERT and controls. For that, we investigated 58 Fabry patients (23 male and 35 female) subdivided into two groups (at diagnosis and during long-term ERT) and compared them to healthy individuals. Fabry patients at diagnosis presented higher lipid peroxidation levels (malondialdehyde - MDA), nitric oxide (NO.) equivalents and urinary Gb3. MDA and NO. equivalents remained higher in patients during long-term ERT, whereas Gb3 levels were lower than at diagnosis but still higher than controls. These data demonstrated that lipid peroxidation and excessive NO. production occur in Fabry patients before and after long-term ERT, probably as a consequence of Gb3 accumulation, providing targets to future therapy approaches using antioxidants in combination with ERT in FD.
748 - Lyso-Gb3 Induces Oxidative DNA Damage in Cultured Kidney Cells
Giovana Brondani Biancini1, Ana Moira Morás2, Luiza Steffens Reinhardt2, Franciele Faccio Busatto2, Tatiane Hammerschimitt3, Camila Delgado4, Nathalia Denise de Moura Sperotto2, Jenifer Saffi2, Dinara Jaqueline Moura2, Roberto Giugliani5, and Carmen Regla Vargas1
1Programa de Pós-Graduação Em Ciências Biológicas: Bioquímica, Ufrgs, Porto Alegre, RS, Brazil
2Laboratório de Genética Toxicológica, Ufscpa, Porto Alegre, RS, Brazil
3Serviço de Genética Médica, Hcpa, Porto Alegre, RS, Brazil
4Programa de Pós-Graduação Em Ciências Farmacêuticas, Ufrgs, Porto Alegre, RS, Brazil
5Departamento de Genética, Ufrgs, Porto Alegre, RS, Brazil
Fabry disease (FD) is a lysosomal disorder caused by mutations leading to a deficient activity of α-galactosidase A with progressive and systemic accumulation of its substrates. Although FD is considered a systemic disorder, renal complications are major causes of morbidity in Fabry patients. Once DNA damage has been associated with disease progression in other chronic diseases and was recently found in high levels in Fabry patients, the main objective of this study was to verify the effects of a FD accumulated substrate on DNA damage in kidney cells. To reproduce pathological conditions, it was tested three concentrations found in Fabry patients (10, 50 and 100 nM) of the latest described biomarker for FD—globotriaosylsphingosine (lyso-Gb3)—in a cultured renal lineage—human embryonic kidney cells (HEK-293 T)—that has been used as a model of epithelial kidney cell-line in renal physiology studies. In all tested concentrations, lyso-Gb3 induced DNA damage (assessed by alkaline comet assay). To investigate a possible oxidative origin in purines and pyrimidines, the comet assay with endonucleases was also performed and again all lyso-Gb3 concentrations induced significant DNA damage when compared to negative control. To the best of our knowledge, this is the first study focusing on these effects of lyso-Gb3 and provides new information that could be useful to studies looking for new therapeutic strategies to slow renal disease progression in FD.
749 - “.Omics” to improve the efficiency of lysosomal disease diagnosis
Maria Fuller, Belinda Mcdermott, Jennifer Saville, and Janice Fletcher
Sa Pathology, Adelaide, Australia
The wide phenotypic variability inherent in lysosomal diseases presents challenges for accurate and timely diagnosis. Diagnostic confusion can also arise from interpretation of the degree of residual enzyme activity and is impractical when the disease is not due to an enzyme deficiency per se. We have profited from advances in mass spectrometry and developed two “.omics” platforms to improve the efficiency of lysosomal disease diagnosis. Employing urine chemistry, as a reflection of multisystemic disease, all ten mucopolysaccharidosis subtypes could be identified from a low molecular weight glycosaminoglycan fingerprint. Ranging in size from mono- to pentasaccharides, with up to two sulfates, these fragments have terminal residues complicit with the enzyme deficiency. From a total of 286 blinded urine samples, 93 were identified as specific mucopolysaccharidosis subtypes with the remainder as controls; this method has now become our urine mucopolysaccharidosis screening test replacing high resolution electrophoresis. Surrogate markers of disease burden, these oligosaccharides are also informative for biochemically monitoring patients in receipt of corrective therapies including bone marrow transplant, enzyme replacement and a gene therapy clinical trial, in which the requisite oligosaccharides decreased, informing on efficacy. A second lipidomics platform provides for the sphingolipidoses following a single-phase lipid extraction of just 0.01 mL of plasma. From a total of 3000 samples, including 16 related inherited metabolic disorders, all 20 Gaucher disease patients were correctly identified. For biochemical monitoring patients in receipt of therapy, some patients returned near normal concentrations (<10 pmol/mL) whereas others were as high as 600 pmol/mL, suggesting that disease burden remains high in some patients. Patients with classical Fabry disease were identified with elevated globotriaosylsphingosine and concentrations remained unchanged in patients receiving replacement therapies. With the addition of sulfatide, confirmation of metachromatic leukodystrophy was afforded with elevated plasma 18:0-sulphatide concentrations, and lyso-sphingomyelin-509 allowed identification of Niemann-Pick C. The opportunity to profile multiple analytes in one assay not only improves diagnostic efficiency but likely provides a clearer picture of disease burden, facilitating both prediction of clinical course and longitudinal biochemical monitoring.
750 - A Pilot Test Evaluating DBS Chitotriosidase in Mexican Patients With Nephropatic Cystinosis
Leticia Belmont-Martinez1, Sandra Del Carmen Mendoza-Ruvalcaba2, and Jose Elias Garcia-Ortiz2
1Instituto Nacional de Pediatria, Ciudad de México, Mexico
2Centro de Investigación Biomedica de Occidente, Guadalajara, Jalisco, Mexico
751 - CentoMD®: Genetic Variants—Related Biomarker Knowledge Database
Gabriela Elena Oprea, Peter Bauer, and Arndt Rolfs
Centogene Ag, Rostock, Germany
Clinical symptoms in lysosomal storage diseases (LSDs) are caused by the deficiency of specific enzymes function and resultant substrate accumulation in the lysosomes. Several biomarkers are already in use as indicators of the presence and monitoring of LSDs: lyso-Gb3 (Gb3) in Fabry disease (FD), Lyso-Gb1 (Gb1) in Gaucher disease (GD) and NP509 in Niemann–Pick (NP) disease. CentoMD® is a browser-based tool that enables access to a high-quality repository of genetic, biochemical and human phenotype ontology (HPO)-based clinical information. All patients provided informed consent before inclusion in the DB. We measured Gb3, Gb1 and NP509 in the DBS samples obtained from 5,603 patients (56.7 females, 39.1 males, 3.3% unknown) undergoing biochemical and genetic testing for verification of FD (71.7%), GD (15.8%) or NP (12.5%). The pathological cutoff for biomarker measurements was set to 1.8 ng/ml for Gb3, to 4.8 ng/ml for Gb1; and to 0.9ng/ml for NP509. Biomarker levels were correlated with clinical severity of the individual patients. The patient cohort (>128 000 genetically screened individuals in CentoMD® v3.3) covers >110 countries worldwide. 85% of patients with metabolic disorders are associated with biomarker data. We have confirmed the presence of the corresponding LSD in 73.1% (75.1% FD, 14% GD, 10.9% (NP) of the screened individuals and the carrier status in 26.9% (62.4% FD, 20.7% GD, 16.9% NP). The observed age at diagnosis varies from 11.9+/13.7 in NP cases, to 22.7 ± 19.6 in GD and 41.2 ± 19.9 in FD (39.9 ± 18.1 in males, 42.7 ± 21.0 in females). The most of the diagnosed LSD cases are originating from Europe (49.8%), followed by Latin America (36.2%), Middle East (9.5%) and Africa (2.4%). The level of biomarkers at time of diagnosis were 3.5+/−2.5 ng/mL for NP509, 299.8 ± 259.5 ng/mL for Gb1 and 3.9 ± 10.3 ng/mL in FD-females, and 19.8 ng/mL ± 32.9 ng/mL in FD-males. We have identified in total 945 unique genetic variants (44.4% are novel), associated with epidemiological information, clinical symptomatology and biomarker levels in CentoMD® (40.4% in FD, 34.8% in GD, and 55.1% in NP). In order to generate reliable predictions of genetic changes in severity and progression of LSDs, we investigated the relationship between the detected genetic variants, biomarker levels and clinical phenotype. CentoMD® brings exceptional quality, unique and valuable information on genetic variants spectrum in different ethnical populations.
752 - Wolman Disease, Atypical Presentation Without Marked Hepatomegaly or Hypertransaminasemia
Javier de Las Heras1, Luis Aldámiz-Echevarria1, Leonor Arranz2, Maite Labayru1, Elena Perez1, Fernando Andrade1, Raquel Yahyaoui3, and Jorge Javier Cebolla4
1Hospital Universitario Cruces, Bilbao, Spain
2Hospital Universitario Donostia, San Sebastián, Spain
3Málaga Regional Hospital, Malaga, Spain
4Centro de Investigación Biomédica En Red de Enfermedades Raras (Ciberer), Zaragoza, Spain
Lysosomal acid lipase deficiency (LALD) is a rare autosomal recessive lysosomal storage disease caused by mutations in the LIPA gene. Patients presenting in infancy have the most rapidly progressive disease, so called Wolman disease, developing signs and symptoms in the first weeks of life and rarely surviving beyond 6 months of age without treatment. The patient, a full-term male newborn with normal birth weight (2880 g) and a history of consanguinity (parents are first-degree cousins), started vomiting and presenting abdominal distension in the first days of life, reason why he was admitted to hospital at 15 days of life. He continued with vomiting, diarrhea, failure to thrive, malabsorption, and developed marked splenomegaly. At 2 months of age he was transferred to our hospital. On physical examination, both weight (3840 g) and length (53 cm) were below the third percentile. He was pale, and abdominal distension with splenomegaly and cachexia were evident. A subtle hepatomegaly about 1-2 cm below the costal margin was present at that moment. Laboratory test showed anemia (Hb: 8.1 g/dL). AST and GGT were slightly elevated [AST: 90 U/L (normal range: 7-80); GGT: 108 U/L (normal range 10-35)], and ALT levels were normal [ALT: 35 U/L (normal range 5-47)]. LDL cholesterol value was normal (LDL: 113 mg/dL), whereas HDL cholesterol was low (12 mg/dL) and triglycerides were elevated (221 mg/dL). Although no marked hepatomegaly or hypertransaminasemia was present, clinical data led to the suspicion of Wolman disease. Blood film examination showed vacuolated lymphocytes (63% of lymphocytes). Acid lipase enzyme activity was null in dried blood sample, and genetic test showed novel mutation in homozygous, located in intron 6 canonical splicing donor. The following laboratory work showed an increase in the transaminases (AST: 188 U/L, ALT: 202 U/L, and GGT: 299 U/L), and hepatomegaly became more evident (about 4 cm below the costal margin) during the following weeks. Conclusions: In an infant with compatible physical examination (malnutrition, abdominal distension) and symptoms (vomiting, diarrhea, malabsorption, and failure to thrive), LALD should be investigated, although not marked hypertransaminasemia or hepatomegaly is present at the moment, as they may develop later. As in other metabolic diseases, in Wolman disease blood film examination for vacuolated lymphocytes can give a cheap, rapid and minimally invasive clue to the diagnosis.
753 - Lysosomal Acid Lipase Deficiency (LAL D): Clinical and Morphological Progression in Children and Young Patients
Tatiana Strokova1, Madlena Bagaeva1, Elena Tumanova2, Alena Grishina2, Elena Kamenets3, and Elena Zakharova3
1Scientific Research Institute of Nutrition, Moscow, Russia
2Pirogov Russian National Research Medical University, Moscow, Russia
3Research Center for Medical Genetics, Moscow, Russia
LAL D is a rare hereditary disease characterized by a progressive course. Objective: to study clinical, laboratory and morphological manifestations in patients with LAL D. Methods: We examined 14 patients aged 2.5 to 21 years (avg. 8.8 ± 1.5 years) with enzymatic and genetically confirmed diagnosis of LAL D. Puncture biopsy of the liver and a morphological examination of the specimen were performed to all patients. Results: At the time of the study, the liver was enlarged in 13 children for 2-8 cm (avg. 4.4 ± 0.6) from under the edge of the costal arch, the spleen in 5 children was palpated below the left costal arch for 1-2 cm. The cytolysis syndrome was confirmed in all patients: AST—105.2 ± 16.1, ALT—132.2 ± 20.6 U/l. Hypercholesterolemia 7.4 ± 0.4 mmol/L and an increase in LDL-C—5.3 ± 0.4 mmol/L were detected in all children, hypertriglyceridemia in 5 patients (2.6 ± 0.3 mmol/L). The index of histological activity was 4.5 ± 0.5 points (Knodell). There were no signs of inflammation in the liver biopsy in 4 patients. Phenomenon of periportal hepatitis of minimal degree of histological activity was registered in 4, low degree—in 6 children. Attention was drawn to the presence of increased hepatocytes in 5 patients. Hepatocytes had a light vacuolized cytoplasm (micro vesicular or mixed steatosis) in all observations. Two children had binuclear hepatocytes. In biopsies of two more patients, the nuclei were shifted to the periphery. During the Schick reaction in 7 patients, the accumulation of the Schick-positive substance in hepatocytes was recorded, which was washed out by amylase control in 3 of them. In all patients, morphological picture was characterized by fibrosis of portal tracts, port-portal septums were detected in 12, perihepatocellular fibrosis in 6 children. The Desmet sclerosis index was 1 point confirmed in 4 (age of children 6.0 ± 2.4 years), 2 points in 7 (age 7.4 ± 1.1 years), 3 points for 3 patients (avg. age 7.5 ± 1.9 years). Thus, patients with LAL D are characterized by the presence of hepatomegaly, cytolysis syndrome, hypercholesterolemia and dyslipidemia due to an increase in LDL-C. Morphological signs of LAL D could be nonspecific. However, the overwhelming majority is determined by vacuolization of the cytoplasm, micro/mixed steatosis, minimal inflammatory changes and the formation of liver fibrosis progressing with age as the duration of the disease increases.
754 - Analytical Scoring Tool Based on Enzyme Activity to Guide the Diagnosis of Pompe Disease Suspected Patients
Tijen Tanyalcin1 and Ibrahim Tanyalcin2
1Tanyalcin Medical Laboratory Selective Screening and Metabolism Unit, Izmir, Turkey
2Self-Employment, Brussels, Belgium
Pompe disease is a storage disorder with a partial or complete deficiency of acid α- glucosidase (GAA). The identification of acarbose as one of the effective inhibitors of isoenzyme maltase glucoamylase (MGA) derived from neutrophils permits the assessment of GAA activity in blood samples, including DBS (dried blood spots). Three enzyme reactions were performed by fluorometric enzymatic assay: 1- GAA, was measured at pH 4.0 in the presence of inhibitor acarbose; 2- total GAA (MGA+GAA) measured at pH 4.0 without acarbose; and 3-Neutral α glucosidase activity (NAG), measured at pH 7.3. The tGAA reflects the combined activity of the isoenzyme MGA and GAA and was measured to calculate the percentage of tGAA that was inhibited by acarbose by using the formula (tGAA - GAA) / tGAA. This study uses a unique scoring system based on GAA, NAG, and tGAA to guide the diagnosis of patients. The scoring system is composed of 10 classifiers, several of which were either taken or adapted from Chien et al., 2008 www.pediatrics.org/cgi/doi/10.1542/peds.2007-2222 Out of these 10 classifiers, 9 of them are binary with values 0 or 1 and the remaining is a floating-point classifier that ranges between −1 and 1. Overall, a given patients score can range between −1 to 10 and effectively incorporates tGAA, NAA, GAA and percent inhibition into the decision process. To get a glimpse of this scoring system’s diagnostic ratio we have tested the algorithm on 35 patients, 28 of whom were healthy. The mean of the healthy population was 0.75 with maximum value, minimum value, +2SD and -2SD intervals being 1.76, −0.05, 1.67, and −0.16, respectively. The mean of the affected patients was 6.9 with maximum value, minimum value, +2SD and −2SD intervals being 10, 3.76, 12 (capped at 10), and 1.867. Based on these values a threshold with a score of 1.8 yields excellent diagnostic odds ratio, classifying all patients correctly.
755 - β-Mannosidosis: Case Report of the First Two Slovak Patients
Jana Saligova1, Anna Salingova2, Ludmila Potocnakova1, Slavka Mattosova3, Jan Saliga4, Darina Behulova2, and Jan Chandoga3
1Department of Pediatrics, Children's Faculty Hospital, Kosice, Kosice, Slovakia
2Comenius Children's Faculty Hospital, Bratislava, Slovakia
3Institute of Medical Biology, Genetics and Medical Genetics, Comenius University, Bratislava, Slovakia
4Tu Kosice, Kosice, Slovakia
756 - Screening Tests for Pompe Disease in 6522 Samples From Colombian Patients, the Need of Confirmation
Alfredo Uribe1, John Gamba2, and Patricia Moreno1
1Universidad de Los Andes, Bogotá, Colombia
2Sanofi-Genzyme, Bogotá, Colombia
Pompe disease is a hereditary disease of the glycogen metabolism. The mutations are transmitted in an autosomal recessive way and affect the molecular structure of lysosomal enzyme α-Glucosidase (EC 3.2.1.20/3). This alteration leads to progressive storage of glycogen in muscle cells lysosome and alteration of other cellular mechanisms generating a broad phenotypic clinical expression including proximal muscle weakness, restrictive respiratory insufficiency, severe hypotony, hyperckemia, macroglosya, and cardiomyopathy between others. Enzymatic analysis techniques for screening and diagnosis have been developed for this specific metabolic disease. The first ones have been developed in solid phase samples (DBS), allowing then to carry out extensive high-risk population screenings. The latter ones have been developed in isolation of total leukocytes, as a confirmation technique for altered cases in the screening tests. Since 2005, screening studies in high-risk populations have been carried out in Colombia, using the DBS technique because of its easy handling, collection and shipping characteristics, achieving a wide coverage above the country. The results of ten years (2006-2015) of screening in high risk population with suggestive findings of Pompe disease submitted to analysis in our center are presented here. A total of 6522 samples on filter paper were analyzed in that period. The age range was 2 months to 95 years. The methodology included an end-point enzymatic assay, using 4MU-alpha-D-glucopyranoside (4MU) as an artificial substrate in the presence of acarbose as an inhibitor of non-disease-related enzyme isoforms. 90 samples with alterations in the enzymatic activity were detected with this screening. Subsequently, these 90 individuals were carried out to a later confirmation using an end-point enzymatic assay with 4MU in acarbose presence, in isolated leukocytes; obtaining enzymatic alteration in 40 individuals, thus confirming the pathology in them. 50 samples (0.72%) show results comparable to normal population values, considering then these individuals, as false positives of DBS screening technique. This finding constrains the confirmation by using complementary tests in all cases and in some of them even to evaluate the enzymatic activity using specific natural substrate (Glycogen) for this entity.
757 - Selective Screening of 32 940 Colombian Patients for the Detection of Lysosomal Metabolic Disorders: Memories of 22 Years of Research (1995-2016)
Alfredo Uribe1 and Adis Ayala2
1Universidad de Los Andes, Bogotá, Colombia
2Universidad Distrital Francisco José de Caldas, Bogotá, Colombia
758 - Characterization of Plasma Lipoprotein Particles in Spanish Patients With Lysosomal Acid Lipase Deficiency
Raquel Yahyaoui1, Enrique Rodríguez-García2, Miriam Gil-Serret3, María Concepción García-Jiménez4, María Luisa González-Diéguez5, Pablo Del Valle Loarte6, Miguel Angel Barba-Romero7, Jesús Quintero-Bernabeu8, David Gil Ortega9, Javier de Las Heras10, Luis Aldámiz-Echevarria10, María Rosa Bernal-López11, Eduardo García-Fuentes12, and Nuria Amigó13
1Malaga Regional University Hospital. Ibima, Malaga, Spain
2Malaga Regional University Hospital. University of Málaga, Malaga, Spain
3Biosfer Teslab, Reus, Spain
4Miguel Servet University Hospital, Zaragoza, Spain
5Central University Hospital of Asturias, Oviedo, Spain
6Severo Ochoa University Hospital, Leganes, Spain
7Albacete University Hospital, Albacete, Spain
8Vall Dʾhebron University Hospital, Barcelona, Spain
9Virgen de La Arrixaca University Hospital, Murcia, Spain
10Cruces University Hospital, Bilbao, Spain
11Málaga Regional University Hospital. Ibima, Malaga, Spain
12Virgen de La Victoria Clinical University Hospital. Ibima, Malaga, Spain
13Biosfer Teslab. Metabolomics Platform, Rovira I Virgili University, Tarragona, Spain
759 - CLN8 Deficiency Impairs Dendritic Development in Hippocampal Neuronal Model
Favio Pesaola1, Gonzalo Quassollo2, Ines Noher de Halac1, and Mariano Bisbal2
1Programa Nclcemeco- Hospital de Niños de La Provincia de Córdoba, Cordoba, Argentina
2Instituto de Investigaciones Médicas “Mercedes Y Martín Ferreyra” (Inimec—Conicet), Cordoba, Argentina
760 - Lysosomal Acid Lipase Deficiency (LAL D): Clinical and Morphological Progression in Children and Young Patients
Tatiana Strokova1, Madlena Bagaeva1, Elena Tumanova2, Alena Grishina2, Elena Kamenets3, Elena Zakharova3, and Svetlana Mikhailova4
1Scientific Research Institute of Nutrition, Moscow, Russia
2Pirogov Russian National Research Medical University, Moscow, Russia
3Research Centre of Medical Genetics, Moscow, Russia
4Russian Children Clinical Hospital, Moscow, Russia
LAL D is a rare hereditary disease characterized by a progressive course. Objective: to study clinical, laboratory and morphological manifestations in patients with LAL D. Methods: We examined 14 patients aged 2.5 to 21 years (avg. 8.8 ± 1.5 years) with enzymatic and genetically confirmed diagnosis of LAL D. Puncture biopsy of the liver and a morphological examination of the specimen were performed to all patients. Results: At the time of the study, the liver was enlarged in 13 children for 2-8 cm (avg. 4.4 ± 0.6) from under the edge of the costal arch, the spleen in 5 children was palpated below the left costal arch for 1-2 cm. The cytolysis syndrome was confirmed in all patients: AST—105.2 ± 16.1, ALT—132.2 ± 20.6 U/L. Hypercholesterolemia 7.4 ± 0.4 mmol/l and an increase in LDL-C—5.3 ± 0.4 mmol/L were detected in all children, hypertriglyceridemia in 5 patients (2.6 ± 0.3 mmol/L). The index of histological activity was 4.5 ± 0.5 points (Knodell). There were no signs of inflammation in the liver biopsy in 4 patients. Phenomenon of periportal hepatitis of minimal degree of histological activity was registered in 4, low degree—in 6 children. Attention was drawn to the presence of increased hepatocytes in 5 patients. Hepatocytes had a light vacuolized cytoplasm (micro vesicular or mixed steatosis) in all observations. Two children had binuclear hepatocytes. In biopsies of two more patients, the nuclei were shifted to the periphery. During the Schick reaction in 7 patients, the accumulation of the Schick-positive substance in hepatocytes was recorded, which was washed out by amylase control in 3 of them. In all patients, morphological picture was characterized by fibrosis of portal tracts, port-portal septums were detected in 12, perihepatocellular fibrosis in 6 children. The Desmet sclerosis index was 1 point confirmed in 4 (age of children 6.0 ± 2.4 years), 2 points in 7 (age 7.4 ± 1.1 years), 3 points for 3 patients (avg. age 7.5 ± 1.9 years). Thus, patients with LAL D are characterized by the presence of hepatomegaly, cytolysis syndrome, hypercholesterolemia, and dyslipidemia due to an increase in LDL-C. Morphological signs of LAL D could be nonspecific. However, the overwhelming majority is determined by vacuolization of the cytoplasm, micro/mixed steatosis, minimal inflammatory changes and the formation of liver fibrosis progressing with age as the duration of the disease increases.
761 - Profile of the Brazilian NPC-C Patients: Preliminary Phenotypic and Genotypic Data
Luciana Giugliani1, Vanessa Van Der Linden2, Helio Van Der Linden Junior3, Charles Lourenço4, Emília Katiane Embiruçu de Araújo Leão5, Juliana H. Arita6, Maria Julia Rodovalho Doriqui7, Pedro Braga Neto8, Carolina Souza1, Dafne Horovitz9, Mara Lucia Santos10, Eugenio Grillo11, Raquel Tavares Boy da Silva12, Janaina Bianca de Oliveira Abrão13, Franciele Trapp1, Maria Luiza Saraiva-Pereira14, Rejane Kessler14, Fernanda Timm Seabra Souza14, and Roberto Giugliani14
1Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
2Associação de Assistência À Criança Deficiente (Aacd Pe), Recife, PE, Brazil
3Hospital Neurologico, Goiana, GO, Brazil
4Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (Usp), Ribeirão Preto, SP, Brazil
5Hospital Universitário Prof. Edgard Santos, Salvador, BA, Brazil
6Universidade Federal do Estado de São Paulo, São Paulo, SP, Brazil
7Complexo Hospitalar Materno-Infantil do Maranhão, São Luis, MA, Brazil
8Hospital Geral de Fortaleza, Fortaleza, CE, Brazil
9Instituto Fernandes Figueira (Iff/ Fiocruz), Rio de Janeiro, RJ, Brazil
10Hospital Pequeno Príncipe, Curitiba, PR, Brazil
11Hospital Infantil Joana de Gusmão, Hijg, Florianópolis, SC, Brazil
12Hospital Universitário Pedro Ernesto, Rio de Janeiro, RJ, Brazil
13Hospital Regional de Barbacena, Barbacena, MG, Brazil
14Hospital de Clínicas de Porto Alegre, Porto Alelgre, RS, Brazil
762 - Neuronal Ceroid Lipofuscinosis: Two Families, Two Forms, Two New Mutations
Havva Yazici1, Ebru Canda1, Sema Kalkan Uçar1, Muzaffer Polat2, Uluc Yis3, Ayca Aykut4, Asude Alpman4, and Mahmut Çoker1
1Division of Pediatric Metabolism and Nutrition, Ege University Faculty of Medicine, Izmir, Turkey
2Division of Pediatric Neurology, Celal Bayar University Faculty of Medicine, Manisa, Turkey
3Division of Pediatric Neurology, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
4Division Medical Genetics, Ege University Faculty of Medicine, Izmir, Turkey
Neuronal ceroid lipofuscinosis (NCL) is a lysosomal storage disease characterized by neurodegeneration, seizure and visual loss. It is most commonly seen neurodegenerative disease group in childhood. The patients regarding two different NCL forms will be presented with clinic, laboratory, imaging and genetic analysis results. A 3-year old male patient born as a result of consanguineous marriage forwarded to our hospital with regression in speech commenced in the 18th month and loss of motor acquisitions, seizures, and ataxia. In his physical examination, it was determined that he lost his speaking ability, had walking ability and had low response to external stimuli. In the cranial MRI scan, cerebral atrophy was established. Palmitoyl-proteinthioesterase (PPT) enzyme activity was 0 nmol/spot 45*h (N:0.25-2.5) and in PPT1 gene analysis, p.H187Y change—undefined previously—was determined as homozygous. A 5-year-old male patient born from a consanguineous marriage forwarded to us with regression in speech at the age of 2.5 years, seizures beginning at the age of 3 years and imbalance in walking added while he was 4 years. On his physical examination, it was established that there was no walking and speech ability, no response to external stimuli, there were involuntary movements on hands. Cerebral and cerebellar atrophy were identified in the cranial MRI scan. In the MFD8 gene analysis concerning the form—late infantile neuronal ceroid lipofuscinosis—known to be common in Turkish society was established as previously undefined Q365X homozygous mutation. In the family screening, the same homozygous mutation was identified in the MFDS8 gene analysis from the 3-year-old sibling with no complaints except for being not able to talk. NCL is one of the diseases that should be considered in the definitive diagnosis of a patient applying to hospital with neurodegeneration.
763 - Glycogen Storage Disease Type 9 is the Most Common Among Cohort of Russian Pediatric Patients With Glycogenosis
Alexander Pushkov, Kirill Savost’Anov, Leyla Namazova-Baranova, Andrey Surkov, Alexey Nikitin, Ilya Zhanin, and Alexander Pakhomov
“National Scientific and Practical Center of Children’s Health” of the Ministry of Health of The Rf, Moscow, Russia
764 - DNA MFSD8/CLN7 Variants of Late Infantile (LI) Neuronal Ceroid Lipofuscinosis in Argentina
Inés Adriana Cismondi1, Romina Kohan1, Favio Pesaola2, Adriana Becerra2, Norberto Guelbert2, and Ines Noher de Halac3
1Facultad de Odontología, Universidad Nacional de Córdoba, Córdoba, Argentina
2Centro de Estudio de Las Metabolopatías Congénitas-Cemeco. Facultad de Ciencias Médicas, Córdoba, Argentina
3Consejo Nacional de Investigaciones Científicas Y Técnicas-Conicet, Córdoba, Argentina
The neuronal ceroid lipofuscinoses (NCLs) are characterized by retinal damage and brain pathology, loss of neurons, neuroinflammation and autofluorescent lipofuscin-like lipopigments. NCLs are caused by mutations in at least 13 different genes. MFSD8/CLN7 underlaying the autosomal recessive CLN7 disease (OMIM#610951) is a childhood neurodegenerative disorder caused by the defective lysosomal membrane protein MFSD8/CLN7. Pathological DNA variants may remain elusive to genomic screening in rare recessive conditions. Our aim is to describe MFSD8/CLN7 DNA variants in Argentina in individuals #1, #2, and #3, males with LI onset ages, refractory seizures 3.6 to 10 years, psychomotor regression, visual failure, ataxia or other movement abnormalities absent, and positive electron microscopy (EM). Screening for DNA variants were either by NGS with NCL panel or PCR/Sanger. #1: onset 4 years, 8 years old, EM curvilinear profiles (CL); NCL-panel result, MFSD8/CLN7 nonsense variant c.103C>T: p.Arg35* hom.; confirmation by Sanger, segregating in the mother. #2 and #3: EM fingerprint-like profiles (FP), diseases CLN1/CLN2/CLN3 excluded; genes CLN5, CN6, MFSD8/CLN7 and CLN8 screened by PCR/ Sanger. #2, onset age 3.6y, death 15y, MFSD8/CLN7 intron 2c.63- 4delC het., segregating from the mother, being absent in 200 control chromosomes of Italian and Norafrican population. It was previously identified as heterozygous in a Polish affected individual. #3, onset age 1.6 years, 20 years old (last seen with 11 years), MFSD8/CLN7 nonsense variant c.1444C>T: p.Arg482* het. described before in one French subject. All the 3 patients showed late infantile onset. Interestingly #1(CLN7-disease index subject) of Spanish-Guarany ancestors, with variant p.Arg35* hom. shows positive EM for CL profiles, while individuals #2 of Antic Yugoslavian-Ukranian-German ancestors, and #3 of Spanish-Italian ancestors, differed in the EM with FP-like profiles seen in the second biopsy, and variants intron 2-c.63-4delC het. and c.1444C>T: p.Arg482* het. both of uncertain pathological significance, the NGS panel/exomic/genomic sequencing is pending. This study underscores the importance of the phenotype study, and highlights the impact of NGS on the genetic characterization of rare recessive conditions. A mosaicism of DNA variants in the brain could be hypothesized, and genomic DNA variants search in cerebrospinal fluid could be informative on the elusive genetic background of some NCLs.
765 - Toward Small-Molecule Therapies for a Juvenile Form of Batten Disease
Ursula Heins Marroquin, Alexander Crawford, Carole Linster, and Paul Jung
Luxembourg Centre for Systems Biomedicine, Belval, Luxembourg
The ATP13A2/PARK9/CLN12 gene encodes a lysosomal P5-type ATPase and several mutations in this gene are known to cause an autosomal recessive form of early-onset Parkinsonism, called Kufor-Rakeb syndrome (KRS). Recently, different mutations in this same gene were identified to lead to neuronal ceroid lipofuscinosis (NCL, also called Batten disease), in members of a Belgian family, and to spastic paraplegia 78 in 5 patients from 3 unrelated families. The link between these neurodegenerative diseases is further supported by studies in animal models, but the molecular mechanism(s) underlying the connection between ATP13A2 deficiency and disease pathogenesis is not understood. Nevertheless, all this indicates that ATP13A2 plays a crucial role in neuronal cells and that its deficiency leads to neurodegeneration. In order to elucidate the molecular mechanisms involved in the pathogenesis, we recently initiated functional studies of the ATP13A2 protein, mainly in the context of the juvenile form of NCL (JNCL), which is characterized by the accumulation of autofluorescent storage material in lysosomes. Taking advantage of the fact that ATP13A2 is highly conserved from yeast to humans, we have developed disease models for the Batten disease and Kufor-Rakeb syndrome variant of ATP13A2 in budding yeast. The results obtained so far with these models point to an implication of ATP13A2 in heavy metal resistance, with potentially different pathways involved for different types of metal. In parallel, we are developing a knock-out model for ATP13A2 in zebrafish which we seek to use for further validation of the phenotypes observed in the yeast model. Additionally, we have developed a screening strategy to exploit the combination of both models for a more rapid identification of bioactive compounds with therapeutic potential as orphan drug candidates for JNCL.
766 - Screening for Farber Disease Using a C26Cer Specific Biomarker in Dry Blood Tests (DBS) Followed by ASAH1 Gene Sequencing
Claudia Cozma1, Marina Hovakimyan1, Marius Iurascu1, Susanne Zielke2, Jan Lukas2, and Arndt Rolfs2
1Centogene Ag, Rostock, Germany
2Albrecht-Kossel-Institute, University of Rostock, Rostock, Germany
Farber disease (FD) is a rare autosomal recessive disease caused by mutations in acid ceramidase gene (ASAH1). FD is characterized by low ceramidase activity, resulting in accumulation of fatty substances, mainly ceramides. At clinical level, Farber disease is manifesting through hallmark symptoms such as: periarticular nodules, lipogranulomas, swollen and painful joints and a hoarse voice or a weak cry; in addition to these, also hepatosplenomegaly, rapid neurological deterioration or developmental delay are reported. Seven different Farber types were described, with phenotypes varying from mild cases with a longer life expectancy to very severe cases, where the patients do not survive past their first year of life. The diagnostic aspects of FD are poorly developed also due to the rarity of the disease and the significant variability of the clinical symptoms. In the present study, the screening for ceramides and related molecules was performed in Farber affected patients (n = 10), carriers (n = 11) and control individuals (n = 192). This study has the highest number of enrolled Farber patients and carriers reported to present. Liquid chromatography multiple reaction mass spectrometry (LC/MRM-MS) studies revealed that the ceramide C26:0 (C26Cer) and especially its cis-isoform (cis-C26Cer) is a highly sensitive and specific biomarker for FD (P < .0001), with pathological values in a range of 39.2-150.0 nmol/L blood (normal range 13.6-23.4 nmol/L blood, N = 192, healthy individuals). We characterized the 2 isoforms of the C26 ceramide by ion mobility—high resolution mass spectrometry (IM-QToF). The new biomarker can be determined directly in the dried blood spot extract with low sample consumption, easy sample preparation, high reproducibility and it presents the possibility of being used in high throughput screenings
767 - The Mutation p.D313Y is Associated With Organ Manifestation in Fabry Disease
Marcel Du Moulin1, Anja F. Koehn2, Amir Golsari2, Simon Dulz3, Yevgeniya Atiskova3, Monica Patten4, Julia Münch4, Maxim Avanesov5, Kurt Ullrich6, and Nicole Muschol1
1Department of Paediatrics, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
2Department of Neurology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
3Department of Ophthalmology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
4University Heart Centre, Department of Cardiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
5Department of Radiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
6Martin Zeitz Centre for Rare Diseases, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
Fabry disease (FD) is a multisystem lysosomal storage disorder caused by mutations in the GLA gene. The clinical significance of the mutation p.D313Y has been debated. We performed a retrospective chart analysis of clinical (neurological, cardiac, renal, ophthalmological), genetic, and biochemical (lyso-globotriaosylsphingosine, lyso-Gb3; enzyme activity) data in all our patients with the mutation p.D313Y. Seventeen patients from 7 families (12 female, 5 male; age range 4-51 years) were included. Typical symptoms and organ manifestations compatible with FD were identified in 13 patients. Cerebrovascular events occurred in 5 females. Pain or acroparaesthesia were reported by 8 patients. Ocular manifestations included cornea verticillata in one patient and mild retinal vascular tortuosity in 7 patients. Lyso-Gb3 was elevated in 2 females who suffered from cerebrovascular involvement. Classical cardiac, renal or skin manifestations could not be identified. The mutation p.D313Y in the GLA gene may lead to organ manifestations and elevation of the Fabry-specific biomarker lyso-Gb3. Neurological symptoms (stroke and pain) and ocular manifestations seem to be the leading findings. Annual routine visits are recommended for patients carrying the p.D313Y mutation. Enzyme replacement therapy should be considered in symptomatic patients.
768 - Lyso-SM-509 is a Highly Specific and Sensitive Biomarker for the Identification of Niemann-Pick Patients—A 30 Months Study
Peter Bauer1, Claudia Cozma1, Gabriela Elena Oprea1, Jan Lukas2, Susanne Zielke2, and Arndt Rolfs2
1Centogene Ag, Rostock, Germany
2Albrecht-Kossel-Institute, University of Rostock, Rostock, Germany
Niemann-Pick Type C (NPC) disease is an autosomal recessive disease caused by mutations in NPC1 or NPC2 genes translated in defects of the lysosomes cholesterol transport system leading to abnormal accumulation of cholesterol and glycolipids in the lysosome. The severity of the NPC symptoms and the fact that treatment options are available makes NPC diagnosis of high most importance. We present data from a 30 months screening study in a global cohort of potential Niemann Pick patients. Diagnosis was performed in a stepwise manner, using lyso-SM-509 biomarker determination, followed by sequencing of NPC1/2 genes. The levels of lyso-SM-509 in blood and can be used for the easy diagnosis of NPC patients and for the monitoring of the disease progression. Determination of lyso-SM-509 is performed by LC/MRM-MS in plasma, serum, EDTA blood and dried blood spots (DBS). We screened over a world-wide cohort using lyso-SM-509 analysis in DBS and we identified 456 NPC individuals (284 affected and 172 carriers) and 233 NPA/B individuals (157 affected and 76 carriers). The diagnosis was confirmed by sequencing of the NPC1/NPC2 by single gene sequencing, NGS, or MLPA. In NPC1/2 sequencing negative patients with increased lyso-SM-509 concentrations the sequencing of sphingomyelinase (SMPD1) gene was done. Lyso-SM-509 has a sensitivity of 100% and specificity of 99.15% for NPC1/2. Most of the NPC cases were diagnosed in the age of 3 to 10 years (30.65%). We could identify over 6797 NPC1 alleles, 73 NPC2 alleles and 1641 SMPD1 alleles. From the 312 unique variants found (213 NPC1, 14 NPC2, and 85 SMPD1) only 142 were previously published (45%). Most NPC cases were linked with detailed clinical information; the most common symptoms were: hepatomegaly (63.6%), splenomegaly (55.8%), neurodevelopment delay (53%), ataxia (35.6%), psychopathology (34.6%), brain atrophy (30.4%), ophthalmoplegia (30.4%), spasticity (30%), dystonia (24.4%), and seizures (20.7%)
769 - A Novel Mutation in the Neu1 Gene Causing Sialidosis Type1 in Two Saudi Patients
Raashda Sulaiman, Ramzan Khusnooda, and Zuhair Al-Hassnan
King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
Sialidosis (OMIM# 256550), an autosomal recessive lysosomal storage disease is caused by mutations in the NEU1 gene encoding the enzyme neuraminidase. Sialidosis is classified into two types on the basis of phenotype and age of onset. Patients with Sialidosis type 1, present at 8-25 years of age with decreasing visual acuity, macular cherry red spots and or myoclonus. Myoclonus is usually an early feature of the disease and begins in the limbs. As the disease progresses they may develop seizures. We report two unrelated Saudi adolescents who presented with macular cherry red spots. They had normal growth, intellect and no dysmorphic features. They had reduced visual acuity and were otherwise asymptomatic. Family history was unremarkable. Cultured fibroblast from one patient showed markedly reduced activity of neuraminidase 0.02 nmol/min/mg (reference: >0.10). However, molecular testing revealed a novel mutation in Neu1 (c.451G>A; p.Val151Ile) which has not been previously reported as pathogenic.
770 - Study on the Use of Forced Oscillation Technique (FOT) in Patients With Lysosomal Storage Diseases
Fatma Al Jasmi1, Afaf Al Blooshi2, and Abdulkader Souid2
1United Arab Emirates University, Abu Dhabi, United Arab Emirates
2UAEU, Al Ain, United Arab Emirates
771 - Body Composition in Infantile Onset Pompe Disease
Federica Deodato, Roberta Taurisano, Alessandra Liguori, and Carlo Dionisi Vici
Bambino Gesù Children’s Hospital, Rome, Italy
772 - Danon Disease in a Female Girl With a Severe Cardiomyopathy—A Case Report
Raquel Silva1 and Evandro Tinoco2
1Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
2Procardiaco Hospital, Rio de Janeiro, RJ, Brazil
Danon disease, also known as X-linked vacuolar cardiomyopathy and myopathy, is caused by mutation in the gene encoding lysosome-associated membrane protein-2Danon disease is an X-linked dominant disorder predominantly affecting cardiac muscle. Multisystem involvement can be observed, leading to more severe clinical manifestations including skeletal muscle involvement, ocular manifestations and mental retardation, specially in male patients. It is caused by mutations in the gene encoding lysosome-associated membrane protein-2 (LAMP2).
773 - Prenatal Hypertrophic Cardiomyopathy due to Danon Disease
Alice Kuster1, Gaelle Caillaux1, Nadir Benbrik1, Benedicte Romefort1, Gilles Simard2, Marie Musquer1, Madeleine Joubert1, Claudine Levaillant1, and Pascale Richard3
1University Hospital of Nantes, Nantes, France
2University Hospital of Angers, Angers, France
3Molecular Genetics, Hopital Pitie-Salpetriere, Paris, France
774 - The Clinical Features and Diagnosis of Metachromatic Leukodystrophy: A Case Series of Turkish Pediatric Patients With Three Novel Mutations
Berna Seker Yilmaz1, Sebile Kilavuz1, Fatma Derya Bulut1, Deniz Kor1, Özlem Hergüner2, Melike Akbal3, Neslihan Özcan2, and Neslihan Mungan1
1Çukurova University Div Ped Metabolism, Adana, Turkey
2Çukurova University Div Ped Neurology, Adana, Turkey
3Intergen Genetic Laboratories, Ankara, Turkey
775 - Oropharyngeal Dysphagia in Infantile-Onset Pompe Disease
Marine Tardieu, Aurore Suchet, Laurence Lambert, Franck Marmouset, Francois Maillot, and François Labarthe
Chru Tours, Tours, France
776 - Simple and Reliable Preparation of Internal Quality Control Material for the Confirmatory Diagnosis of Lysosomal Storage Disease
Katerina Betta, Maria Angélica Letelier, Karen Fuenzalida, Alf Valiente, and Juan Francisco Cabello
Inta, Universidad de Chile, Santiago, Chile
Confirmatory diagnosis of lysosomal storage diseases (LSD) is performed by determination of lysosomal enzymatic activities in different biological fluids. Internal quality assurance system for lysosomal enzyme analysis is complex because commercial control samples for enzyme assays are not available. We developed and evaluated leukocytes homogenates as internal quality control (QC) material for their use in the confirmatory lysosomal enzymatic assays.
777 - Nephrophatic Cystinosis: Report of Mexican Population
Leticia Belmont-Martinez1, Marcela Vela-Amieva2, Cynthia Fernandez-Lainez2, Sara Guillén López2, Lizbeth Lopez-Mejia2, and Isabel Ibarra-Gonzalez2
1Instituto Nacional de Pediatria, Ciudad de México, Mexico
2Instituto Nacional de Pediatria, Ciudad de Mexico, Mexico
V) Lysosomal Disorders: Treatment, Enzyme Replacement Therapy (778 to 813)
778 - Anti-Agalsidase Antibodies are Associated With Severe Kidney Disease and Truncated Alpha-Galactosidase A in Fabry Disease
Wladimir Mauhin1, Olivier Lidove2, Damien Amelin1, Foudil Lamari3, Catherine Caillaud4, Claire Douillard5, Bertrand Dussol6, Vanessa Leguy-Seguin7, Esther Noel8, Thierry Zenone9, Marie-Benedicte Matignon10, François Maillot11, Kim Heang Ly12, Gerard Besson13, Marjolaine Willems14, Agathe Masseau15, Christian Lavigne16, Didier Lacombe17, Eric Hachulla18, and Olivier Benveniste1
1Institute of Myology, Inserm, Upmc, Paris, France
2Internal Medicine and Rheumatology Department, Diaconesses-Croix Saint Simon Hospital Group, Paris, France
3Metabolic Biochemistry Department, Pitié Salpêtrière University Hospital, Aphp, Paris, France
4Biochemistry, Metabolomic and Proteomic Department, Necker Enfants Malades University Hospital, Paris, France
5Reference Center For Inborn Metabolic Diseases, Jeanne de Flandres Hospital, Lille, France
6Nephrology Department, Ap-Hm, Marseille, France, Marseille, France
7Internal Medicine and Clinical Immunology Department,- Francois Mitterrand Hospital, Dijon, France
8Internal Medicine Department, Strasbourg University Hospital, Strasbourg, France
9Internal Medicine Department, Valence Hospital, Valence, France
10Nephrology And Renal Transplantation Department, Institut Francilien de Recherche En Néphrologie, Creteil, France
11Internal Medicine Department, Tours University Hospital, François Rabelais University, Umr Inser, Tours, France
12Internal Medicine Department, Dupuytren University Hospital, Limoges, France
13Neurology Department, Grenoble University Hospital, Grenoble, France
14Medical Genetics and Rare Diseases Department, Montpellier University Hospital, Montpellier, France
15Internal Medicine Department, Hôtel-Dieu University Hospital, Nantes, France
16Internal Medicine and Vascular Diseases Department, Angers University Department, Angers, France
17Medical Genetics Department, University Hospital of Bordeaux, Inserm U1211, Bordeaux University, Bordeaux, France
18Internal Medicine Department, Huriez Hospital, University of Lille, Lille, France
Fabry disease (FD) is a progressive and multisystemic X-linked disease in which mutations in GLA gene lead to alpha-galactosidase A deficiency with subsequent increase of glycosphingolipids such as LysoGb3. Enzyme replacement therapy (ERT) with agalsidase alfa or agalsidase beta has been available since 2001 in Europe with the development of anti-agalsidase antibodies of unclear significance. We aimed to determine the clinical and biological impact of these antibodies. From December 2014, we have initiated the French FAbry Biobank and RegistrY (FFABRY) as a multicenter, independent, and collaborative clinical database associated with a biobank gathering biological samples from French patients with genetic and/or enzymatic diagnosis of FD, treated or not with ERT. Anti-agalsidase status for both ERT was prospectively assessed with a home-made ELISA. Plasma Lyso-Gb3 was measured with by ultra-performance liquid chromatography coupled to tandem mass spectrometry (UPLC-MS/MS). Enzyme inhibition assays were performed in plasma and PBMCs. Among the 103 patients (53 males) included, 18 of the 45 (40.0%) males and 2 of the 25 (8.0%) females exposed to agalsidase were seropositive without difference between molecules. Antibody titers were correlated with enzymatic inhibition (r 2>0.77, P < .0001) and plasma lysoGb3 in men (r 2 = 0.52; P < .0001). All IgG subclasses were observed but IgG4 reached the highest concentrations (0.05 to 1.45 mg/mL). Seropositivity, but not serum inhibition was associated with higher frequencies of renal transplantation or dialysis (hazard ratio 30.2; P = .002). Mutations leading to truncated alpha-galactosidase A were significantly associated with antibodies (relative risk 2.88; P = .006) in men and correlated with worse cardiac MSSI in women. Anti-agalsidase antibodies are associated with a more severe renal disease and higher plasma lysoGb3. Systematic and independent screening for anti-agalsidase antibodies and associated mutations should be performed in FD patients. A better understanding of the role of genotype in antibody development is needed. New therapeutical algorithm should already be defined: (i) increase the dose of ERT, (ii) associate or switch to chaperone therapy to hide epitopes, and/or (iii) use immunosuppressive therapies.
780 - Evaluation of a Case With Niemann-Pick Type C Under Miglustat Therapy
Sahin Erdol, Sevil Dorum, and Halil Saglam
Uludag University Faculty of Medicine, Bursa, Turkey
781 - Early Hematopoietic Stem Cell Transplantation in a Patient With Severe Mucopolysaccharidosis II: A 7 Years Follow-Up
Anneliese Barth1, Tatiana Magalhães2, Ana Beatriz Reis1, Maria Lucia Oliveira3, Fernanda Scalco3, Nicolette Cavalcanti1, Danielle Torres1, Daniel Silva1, Alessandra Costa1, Carmem Bonfim4, Roberto Giugliani5, Juan Llerena Jr1, and Teste I1
1Iff/Fiocruz, Rio de Janeiro, RJ, Brazil
2Biomarin, Rio de Janeiro, RJ, Brazil
3Labeim/Ufrj, Rio de Janeiro, RJ, Brazil
4Hcpr, Curitiba, PR, Brazil
5Hcpa, Porto Alegre, RS, Brazil
Mucopolysaccharidosis type II (MPS II - Hunter syndrome) is an X-linked lysosomal storage disorder caused by a deficiency in the enzyme iduronate-2 sulfatase (I2 S), leading to the accumulation of the glycosaminoglycans, affecting multiple organs and systems. Enzyme replacement therapy does not cross the blood brain barrier, limiting results in neurological forms of the disease. Another option of treatment for severe MPS, hematopoietic stem cell transplantation (HSCT) has become the treatment of choice for the severe form of MPS type I, since it can preserve neurocognition when performed early in the course of the disease. To date, only few studies have examined the long-term outcomes of HSCT in patients with MPS II. We describe the seven-year follow-up of a prenatally diagnosed MPS II boy with positive family history of severe MPS form, submitted to HSCT with umbilical cord blood cells at 70 days of age. Engraftment after 30 days revealed mixed chimerism with 79% donor cells; after 7 years engraftment remains at 80%. I2 S activity 30 days post-transplant was low in plasma and normal in leukocytes and the same pattern is observed to date. At age 7 years growth charts are normal and he is very healthy, although mild signs of dysostosis multiplex are present, as well as hearing loss. The neuropsychological evaluation (Wechsler Intelligence Scale for Children—Fourth Edition—WISC-IV), disclosed an IQ of 47. Despite this low measured IQ, the patient continues to show improvements in cognitive, language and motor skills, being quite functional. We believe that HSCT is a therapeutic option for MPS II patients with the severe phenotype, as it could preserve neurocognition or even halt neurodegeneration, provided strict selection criteria are followed.
782 - Monitoring Physical Activity Using a Wearable Device in Pompe Disease
Alaa Hamed1, Pronabesh Dasmahapatra2, Christopher Curran2, and Ryan Black2
1Sanofi Genzyme, Cambridge, MA, USA
2Patientslikeme, Cambridge, MA, USA
Late-onset Pompe disease (LOPD) is a rare metabolic disease with an age of onset of ≥ 1 year. Patients experience a progressive decline in respiratory and skeletal muscle function which can lead to decreased mobility as well as respiratory weakness. Activity tracking devices offer a unique opportunity to monitor Pompe patients’ mobility in real world settings. The Pompe Disease Symptom Scale (PDSS) is a newly developed instrument aimed at capturing the disease symptoms from patients’ perspective. The scale captures breathing difficulties, fatigue and tiredness, muscle weakness and muscle ache, pain, and headache. Part of the ongoing validation work for this instrument includes administering it to Pompe patients and exploring correlations between the PDSS scores and patient monitored activities using a commercially available activity tracker. The objectives are to 1) Evaluate the measurement properties of the PDSS; 2) Explore the relationship between patient reported symptom severity and device measured activity, which includes step count, distance, and elevation, using an activity tracker in a real-world setting. LOPD patients were given Fitbit One devices for 6-8 weeks for activity monitoring and separately engaged in observational data donation on the PatientsLikeMe website. PDSS scores were captured at baseline and exit; during the study patients also reported general and Pompe specific symptoms on the PatientsLikeMe portal. Daily activity, including steps, patient engagement, and peak 6-min walk intervals were measured during the study. Psychometric properties of the PDSS were tested to develop a preliminary score. The association between PDSS and device measured activity were examined. Median age of patients enrolled was 44 years, 83% (n = 29) female, with 94% diagnosed ≥ 18 years (n = 33). Median activity (step count) of the population was less than other publically available chronic disease populations (∼3000 steps/day), activity patterns varied by age, age at onset, PDSS, and use of enzyme replacement treatment (ERT). Baseline PDSS was negatively correlated with total steps (r = -0.32) and peak 6-min walk test (r = −0.52). Members in the first quartile of the PDSS (least severe) reported nearly twice as much activity as members in all other quartiles. Using activity trackers as part of validation activities for newly developed PRO instruments offer novel insights from the real world on the interpretation of instrument scores.
783 - Pegunigalsidase Alfa for Treating Fabry disease—Immunogenicity and Pharmacokinetics Results From Phase 1/2 Studies
David G. Warnock1, Derralynn Hughes2, Simeon Boyd3, Pilar Giraldo4, Derlis Gonzales5, Myrl Holida6, Ozlem Goker-Alpan7, Gustavo Maegawa8, Mohamed Atta9, Kathy Nicholls10, Raphael Schiffmann11, Ahmad Tuffaha12, Martha R. Charney13, Raul Chertkoff14, Sari Alon14, and Einat Brill-Almon14
1University of Alabama at Birmingham, Department of Medicine, Birmingham AL, USA
2Lsdu, Institute of Immunity and Transplantation, Royal Free London Nhs Foundation Trust, London, United Kingdom
3Department of Pediatrics, Section of Genetics, Mind Institute, UC Davis Medical Center, Sacramento, CA, USA
4Hospital de Dia Quiron, Zaragoza, Spain
5Instituto Privado de Hematologia Investigacion Clinica, Asunción, Paraguay
6Medical Genetics-Lysosomal Storage Disorders, University of Iowa, Iowa City, IA, USA
7O&O Alpan Llc, Fairfax, VA, USA
8Department of Pediatrics/Genetics & Metabolism, University of Florida, Gainesville, FL, USA
9Department of Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
10Nephrology Department, The Royal Melbourne Hospital, Melbourne, Australia
11Baylor Institute of Metabolic Diseases, Baylor University Medical Center, Dallas, TX, USA
12Kansas University Medical Center, Kansas City, KA, USA
13Pharmacokinetics Consultant, Toronto, Canada
14Protalix, Carmiel, Israel
Pegunigalsidase alfa (PRX-102) is a novel, PEGylated, chemically modified, α-galactosidase A enzyme replacement therapy for the treatment of Fabry disease (FD). Immune responses to therapeutic protein could potentially impact its efficacy and/or safety. In FD, an X-linked disorder caused by the loss of function of the lysosomal enzyme α-galactosidase-A, anti-drug antibody (ADA) formation toward the enzyme has been shown to occur in a high percentage of male patients, especially with nonsense mutations.
784 - Characterization of a Chemically Modified Plant Cell Culture Expressed Human α-Galactosidase-A Enzyme for Treatment of Fabry Disease
Yoseph Shaaltiel, Yaniv Azulay, Daniel Bartfeld, Yakir Nataf, Yoram Tekoah, Gil Arvatz, Avidor Shulman, Ilya Ruderfer, and Tali Kizhner
Protalix, Carmiel, Israel
Fabry disease is an X-linked recessive disorder caused by the loss of function of the lysosomal enzyme α-Galactosidase-A. Pegunigalsidase alfa (PRX-102) is a novel enzyme for the therapy of Fabry disease expressed in a BY2 Tobacco cell culture. Pegunigalsidase alfa is chemically modified, resulting in a cross-linked homo-dimer.
785 – One-Year Follow-Up Safety and Efficacy of Fabry Disease Patients Treated by IV Administration of Pegunigalsidase Alfa—A Novel, PEGylated, and Cross-Linked Homodimer α-Galactosidase-A Enzyme
Raphael Schiffmann1, Derralynn Hughes2, Simeon Boyd3, Pilar Giraldo4, Derlis Gonzales5, Myrl Holida6, Ozlem Goker-Alpan7, Gustavo Maegawa8, Mohamed Atta9, Kathy Nicholls10, Ahmad Tuffaha11, Laura Barisoni12, Robert Colvin13, J.Charles Jannette14, Sari Alon15, Jenny Krupko15, Mali Szlaifer15, Einat Brill-Almon15, and Raul Chertkoff15
1Baylor Institute of Metabolic Diseases, Baylor University Medical Center, Dallas, USA
2Lsdu, Institute of Immunity and Transplantation, Royal Free London Nhs Foundation Trust, London, United Kingdom
3Department of Pediatrics, Section of Genetics, Mind Institute, UC Davis Medical Center, Sacramento, USA
4Hospital de Dia Quiron, Zaragoza, Spain
5Instituto Privado de Hematologia Investigacion Clinica, Asunción, Paraguay
6Medical Genetics-Lysosomal Storage Disorders, University of Iowa, Iowa City, USA
7O&O Alpan Llc, Fairfax, USA
8Department of Pediatrics/Genetics & Metabolism, University of Florida, Gainesville, USA
9Department of Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, USA
10Nephrology Department, The Royal Melbourne Hospital, Melbourne, Australia
11Kansas University Medical Center, Kansas City, USA
12University of Miami, Department of Pathology, Miami, USA
13Massachusetts General Hospital, Harvard Medical School, Department of Pathology, Boston, USA
14University of North Carolina, Department of Pathology, Chapel Hill, USA
15Protalix, Carmiel, Israel
Fabry Disease (FD) is an X-linked disorder caused by the loss of function of the lysosomal enzyme α-galactosidase-A. Pegunigalsidase alfa (PRX-102) is a novel, PEGylated chemically modified α-galactosidase A, which makes the enzyme a more stable homo-dimer, expressed in ProCellEx® system using plant cell line in suspension. The enzyme has enhanced pharmacokinetic properties including a half-life of approximately 80 hours, and substantially higher AUC (overall enzyme amount). The current report is a 1-year follow-up of FD patients treated with Pegunigalsidase alfa including subgroup analysis of a classic phenotypic presentation of the disease as part of two phase 1/2 clinical studies: PB-102-F01 and its extension study PB-102-F02.
786 - ERT and intrathecal baclofen Therapy in Patient With Hunter syndrome
Vladimir Bzduch1, Michal Petrik2, Dana Dubravova2, Jarmila Hornova1, Katarina Brennerova1, Darina Behulova3, and Frantisek Horn2
1Department of Pediatrics, Comenius University Children's Hospital, Bratislava, Slovakia
2Department of Pediatric Surgery, Comenius Universit Children's Hospital, Bratislava, Slovakia
3Department of Laboratory Medicine, Comenius University Children's Hospital, Bratislava, Slovakia
787 - Long-Term Safety and Efficacy of Intracerebroventricular Enzyme Replacement Therapy With Cerliponase Alfa in Children With CLN2 Disease: Interim Results From an Ongoing Multicenter Extension Study
Marina Trivisano1, Angela Schulz2, Nicola Specchio1, Paul Gissen3, Emily de Los Reyes4, Heather Cahan5, Peter Slasor5, Temitayo Ajayi5, and David Jacoby5
1Bambino Gesù Children's Hospital, Irccs Rome, Rome, Italy
2University Medical Center Hamburg-Eppendorf, Hamburg, Germany
3Great Ormond Street Hospital for Children, London, United Kingdom
4Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
5Biomarin Pharmaceutical Inc., Novato, CA, USA
788 - Antibody Formation to Enzyme Replacement Therapy in Classic Infantile Pompe Disease: Effects of Immunomodulation in Naive Patients
Esther Poelman1, Marianne Hoogeveen–Westerveld1, Marian Kroos-De Haan1, Hannerieke Van Den Hout1, Kees Bronsema2, Nico Van de Merbel2, Pim Pijnappel1, and Ans Van Der Ploeg1
1Erasmus Mc, Rotterdam, the Netherlands
2Bioanalytical Laboratory, Pra Health Sciences, Assen, the Netherlands
789 - Successful Allogeneic Bone Marrow Transplantation From a Carrier Sibling for the Treatment of Alpha Mannosidosis
Pinar Haznedar1, F. Tuba Eminoglu2, Talia Ileri3, Elif Ince3, and Mehmet Ertem3
1Ankara University Faculty of Medicine, Department of Pediatrics, Ankara, Turkey
2Ankara University Faculty of Medicine, Department of Pediatrics, Division Pediatric Metabolism, Ankara, Turkey
3Ankara University Faculty of Medicine, Department of Pediatrics, Division Pediatric Hematology, Ankara, Turkey
790 - A Rare Case of Fabry Cardiomyopathy Requiring Permanent Pacemaker and Implantable Cardioverter-Defibrillator Despite Enzyme Replacement Therapy
Sang Hyun Park, Kyung Tae Jung, Yu Jeong Choi, Won-Ho Kim, Ki-Woon Kang, and Jung Yeon Chin
Eulji University Hospital, Daejeon, South Korea
A 58-year-old male farmer referred to our hospital due to ECG abnormality, dyspnea on exertion and cardiac enzyme elevation after diagnosis of scrub typhus at local clinic. A 12-leads electrocardiogram (ECG) revealed normal sinus rhythm with 1st degree atrioventricular block (AVB), complete right bundle branch block (RBBB) and pathologic Q wave in I, II, aVL, V5 and V6. Transthoracic echocardiogram showed diffuse severe concentric hypertrophy of the left ventricle (LV) of an average ventricular wall thickness of 30 mm. A dynamic left ventricular outflow track obstruction LVOT) was observed during the Valsalva maneuver. Right ventricle (RV) was also hypertrophied (RV free wall thickness, 9 mm). Cardiac magnetic resonance imaging revealed diffuse delayed hyper-enhancement with various degrees of transmurality. More detailed familial history taking informed that his younger brother and older sister suffered from cardiac problem. His oldest sister died of sudden cardiac death at the age of 60. Genetic disorder was suspected and confirmed as Fabry disease (FD) via GLA gene sequencing. A missense mutation was identified at exon 6 within a GLA gene. The mutation is known to cause FD of a cardiac variant type by literature review. Additionally, 4 family members were confirmed to have FD with same mutation. Index patient initiated enzyme replacement therapy (ERT) with intravenous agalsidase-beta via outpatient department (OPD). Follow-up ECG showed first degree AVB and left bundle branch block (LBBB). He experienced two episodes of syncope and frequently complained of dizziness during OPD follow-up. ECG revealed complete AVB. Beta blocker was discontinued more than two weeks after that. However, complete AVB didn’t improve. Permanent pacemaker (PPM) which has a function of implantable cardioverter-defibrillator (ICD) was implanted considering that he has high risk features of sudden cardiac death such as syncope, severe hypertrophy of LV septal wall and family history of sudden cardiac death. Peak pressure gradient of LVOT markedly decreased to 36 mmHg after PPM implantation from 63 mmHg before that. Symptoms of dyspnea and dizziness also markedly improved. Progression of Fabry cardiomyopathy can lead to severe conduction dysfunction such as complete AVB requiring PPM despite ERT. It suggests that treatment must be initiated early in the course of the disease to be optimally effective.
791 - Urinary Glycosaminoglycan Levels in a Mucopolysaccharidosis Type II Pediatric Population Aged ≤18 Months Receiving Idursulfase Therapy: Data From the Hunter Outcome Survey (HOS)
Barbara Burton1, Kirk Aleck2, Anna Tylki-Szymanska3, Can Ficicioglu4, Virginie Jego5, and Nathalie Guffon6
1Division of Genetics, Birth Defects and Metabolism, Ann & Robert H Lurie Children’s Hospital, Chicago, IL, USA
2Division of Genetics and Metabolism, Phoenix Children's Hospital, Phoenix, AZ, USA
3Department of Pediatric Nutrition & Metabolic Diseases, Children’s Memorial Health Institute, Warsaw, Poland
4Division of Human Genetics and Metabolism, The Children's Hospital of Philadelphia, PA, USA
5Cytel, Inc., Geneva, Switzerland
6Centre de Référence Des Maladies Héréditaires Du Métabolisme, Hôpital Femme Mère Enfants, Bron, France
Specific treatment for mucopolysaccharidosis type II (MPS II; Hunter syndrome) is available in the form of intravenous enzyme replacement therapy (ERT). Idursulfase (Shire, Lexington, MA, USA) stabilizes or improves many of the somatic features of MPS II in patients aged ≥ 5years; tolerability and initial efficacy outcomes in patients starting Idursulfase therapy aged 1.4–7.5 years have been shown to be similar to those of the first clinical studies but experience in patients aged ≤ 18 months remains limited. Our ability to diagnose MPS II early in life is improving, creating a need for increased understanding of the impact of early initiation of ERT. We analyzed data from patients enrolled in the HOS global, observational registry who started Idursulfase aged ≤ 18 months (n = 45 prospective patients; all male; June 2016). Patients were diagnosed at a median (P10, P90) age of 0.4 (0.0, 1.3) years; symptom onset was at age 0.4 (0.0, 1.1) years. Almost half had cognitive impairment (48.8%; 20/41). Patients had received Idursulfase for 53.3 (2.1, 91.9) months, starting at age 0.8 (0.2, 1.4) years; three individuals stopped ERT and never re-started. Sixteen patients started Idursulfase at < 6 months (median 0.3 [0.0, 0.4] years). Urinary glycosaminoglycan (uGAG) measurements (dimethylmethylene blue spectrophotometric assay, adjusted for urine creatinine; n = 33 patients) showed a trend toward a decrease from elevated baseline levels with Idursulfase therapy. Among those with data at both baseline and 1 year of Idursulfase (n = 11), uGAG levels changed by −61.6% (−81.8, 44.1%). Between baseline and year 2 (n = 9), the change was −73.5% (−87.7, 115.7%). As yet, patient numbers are low, but current findings indicate decreased uGAG levels following Idursulfase therapy in this group. Additional follow-up and analysis of a range of clinical outcomes will further increase our understanding of early treatment with Idursulfase. Previously presented at WORLDSymposium 2017.
792 - COMET Methodology: Comparison of the Efficacy and Safety of the Enzyme Replacement Therapies, NeoGAA and Alglucosidase alfa, in Treatment-Naive Patients With Late-Onset Pompe Disease
Volker Straub1, Young-Chul Choi2, Jordi Díaz Manera3, Pascal Laforêt4, Kristina An Haack5, Lingling Li6, and Shafeeq S Ladha; On Behalf of the Comet Trial Investigators7
1Newcastle University John Walton Muscular Dystrophy Research Centre, Newcastle Upon Tyne, United Kingdom
2Department of Neurology, Gangnam Severance Hospital, Yonsei University College of Medicine, Kangnum-Gu, Seoul, South Korea
3Unitat de Malalties Neuromusculars, Hospital de La Santa Creu I Sant Pau de Barcelona, Barcelona, Spain
4Paris-Est Neuromuscular Center, Université Pierre Et Marie Curie Hôpital Pitié-Salpêtrière, Paris, France
5Sanofi Genzyme, Chilly-Mazarin, France
6Sanofi Genzyme, Cambridge, MA, USA
7Barrow Neurological Institute at St Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
Pompe disease is caused by deficiency in the lysosomal enzyme acid alpha glucosidase (GAA), responsible for lysosomal glycogen breakdown. Consequently, glycogen accumulates in body tissues, particularly cardiac and skeletal muscles, leading to progressive muscle weakness and respiratory failure. Alglucosidase alfa, a recombinant human GAA (rhGAA), was the first treatment approved for Pompe disease. NeoGAA, an investigational second-generation rhGAA, was designed to enhance glycogen clearance and improve clinical efficacy. This abstract describes the COMparative Enzyme replacement Trial (COMET; NCT02782741) methodology, which is designed to evaluate the efficacy and safety of neoGAA vs alglucosidase alfa in treatment-naïve patients with late-onset Pompe disease (LOPD). COMET is a Phase 3, multicenter, multinational, randomized, double-blind trial in treatment-naïve LOPD patients, aged ≥3 years, who at baseline are ambulatory for 40 m (without stopping/using assistive device), are not on invasive ventilation, and have ≥30 to ≤85% upright predicted forced vital capacity [FVC]). To control the number of patients with high baseline FVC, ≤15% of those enrolled will have baseline FVC ≥80% predicted. The target enrolment is 96 patients (non-inferiority test: 80% power with assumed treatment difference 2.0% predicted FVC; superiority test: 85% power with 3.5% predicted FVC). Patients randomized 1:1, with stratification on baseline FVC, sex, age, and country (Japan/ex-Japan), receive 20 mg/kg neoGAA or alglucosidase alfa IV qow for 49 weeks. They then enter an open-label, long-term follow-up phase (≤96 weeks) and receive 20 mg/kg neoGAA IV qow. The primary objective of the trial is to determine the efficacy of neoGAA on respiratory muscle strength, as measured by upright FVC % predicted. Other assessments include: functional endurance, inspiratory, expiratory, and extremity muscle strength, motor function, health-related quality of life, patient-reported outcomes, pharmacokinetics, and safety. The first patient enrolled in the trial in November 2016 and the estimated completion is October 2020. The results from the 49-week primary analysis period should identify whether there are any treatment outcome differences between neoGAA and alglucosidase alfa. This trial is sponsored by Sanofi Genzyme.
793 - Efficacy and Safety of Migalastat, an Oral Pharmacological Chaperone for Fabry Disease: Renal Findings From Two Randomized Phase 3 Studies (FACETS and ATTRACT)
Ana Jovanovic1, Raphael Schiffmann2, Kathy Nicholls3, Ulla Feldt-Rasmussen4, Roberto Giugliani5, Daniel G Bichet6, Derralynn Hughes7, Vipul Jain8, Julie Yu8, Jeffrey Castelli8, Nina Skuban8, and Jay Barth8
1Salford Royal Hospital and Nhs Foundation Trust, Manchester, United Kingdom
2Baylor Research Institute, Dallas, TX, USA
3Royal Melbourne Hospital, Parkville, Australia
4Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
5Medical Genetics Service, Hcpa/Ufrgs, Porto Alegre, RS, Brazil
6Hôpital Du Sacré-Coeur, University of Montreal, Montreal, Canada
7Royal Free Nhs Foundation Trust and University College London, London, United Kingdom
8Amicus Therapeutics, Inc., Cranbury, NJ, USA
Fabry disease is an X-linked disorder of lysosomal α-galactosidase A (α-Gal A) deficiency, leading to substrate accumulation, multiorgan disease, and progressive decline in renal function. Accumulation of globotriaosylceramide (GL-3) in the kidney is a known consequence of Fabry disease. We examined whether administration of Migalastat, an oral pharmacological chaperone that induces proper folding of specific mutant forms of α-Gal A and increases trafficking to lysosomes, helps stabilize renal function in patients with Fabry disease. Two randomized phase 3 studies were conducted for Migalastat 150 mg every other day. FACETS (011, NCT00925301) was a 24-month trial, including a 6-month double-blind, placebo-controlled period, in 67 enzyme replacement therapy (ERT)–naive patients. ATTRACT (012, NCT01218659) was an active-controlled, 18-month trial in 57 ERT-experienced patients with a 12-month open-label extension (OLE). Efficacy analyses focused on patients with amenable mutations (FACETS, n = 50; ATTRACT, n = 53). A post hoc analysis examined the eGFR annualized rate of change from baseline in the range of 60 to <90 or >90 mL/min/1.73 m2; the range of 30 to <60 mL/min/1.73 m2 was not included due to the low number of patients in this group. In FACETS, analyses revealed statistically significant reductions in kidney interstitial capillary GL-3 from months 0 to 6 (placebo-controlled; P = .008) and months 6 to 12 (P = .014). Over 24 months, the annualized rate of change in eGFRCKD-EPI ± SD with Migalastat was −0.3±4.2 mL/min/1.73 m2. The annualized rate of change ± SD for eGFR in the range of 60 to <90 mL/min/1.73 m2 (−0.8 ± 4.16) was comparable to the rate in the range of ≥90 mL/min/1.73 m2 (0.2 ± 4.11). During the 18-month controlled period of ATTRACT, the annualized means ± SD for eGFR for Migalastat (−0.40 ± 4.3) and ERT (−1.03 ± 7.4) were comparable. The annualized rates of change in eGFR ± SD in the range of 60 to <90 mL/min/1.73 m2 for Migalastat and ERT were −0.2 ± 5.32 and −7.3 ± 15.90, respectively; the annualized rates in the range of ≥90 mL/min/1.73 m2 were −2.0 ± 2.15 and −2.1 ± 5.30. Predefined renal events occurred in 24% and 33% of patients on Migalastat and ERT, respectively. During the 12-month OLE, eGFR remained stable. In FACETS and ATTRACT, renal function remained stable with Migalastat across patient subgroups. Migalastat has promise as a first-in-class oral chaperone for patients with Fabry disease with amenable mutations. This is an encore abstract.
794 - Long-Term Migalastat Treatment Stabilizes Renal Function in Patients With Fabry Disease: Results From a Phase 3 Clinical Study (AT1001-041)
Charles Lourenço1, Raphael Schiffmann2, Kathy Nicholls3, Daniel G Bichet4, Ulla Feldt-Rasmussen5, Derralynn Hughes6, Julie Yu7, Jeffrey Castelli7, Nina Skuban7, and Jay Barth7
1Ribeirão Preto Medical School, University of São Paulo, São Paulo, SP, Brazil
2Baylor Research Institute, Dallas, TX, USA
3Royal Melbourne Hospital, Parkville, Australia
4Hôpital Du Sacré-Coeur, University of Montreal, Montreal, Canada
5Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
6Royal Free Nhs Foundation Trust and University College London, London, United Kingdom
7Amicus Therapeutics, Inc., Cranbury, NJ, USA
Progressive nephropathy is a hallmark of Fabry disease, a rare X-linked disorder of lysosomal α-galactosidase A (α-gal A) deficiency that results from lysosomal deposition of globotriaosylceramide and can lead to the complications of end-stage renal disease, dialysis, and renal transplantation. Progressive impairment of renal function has also been shown to be a major risk factor for cardiac events and premature death. Stabilizing or slowing renal decline is an important treatment goal in Fabry disease. Oral Migalastat (approved in the EU in 2016; in clinical development in the US) was designed to chaperone specific amenable mutant forms of α-gal A to lysosomes where the enzyme catabolizes accumulated disease-causing substrates. The long-term effects of Migalastat on GFR in enzyme replacement therapy (ERT)-naive patients with Fabry disease from the phase 3 extension study AT1001-041 (NCT01458119) were investigated. Patients completing clinical studies with Migalastat were eligible to enroll in the extension study and receive open-label Migalastat 150 mg every other day. Annualized rate of change in eGFRCKD-EPI was calculated using simple linear regression. One hundred twenty-seven patients with Fabry disease were enrolled in two phase 3 studies. All 54 ERT–naive patients completing the phase 3 study enrolled in the extension study and received open-label Migalastat for a mean of 3.4 years (range 1.5-4.9 years). Patients (male and female) receiving Migalastat had a mean annualized rate of change for eGFRCKD-EPI of −0.7 mL/min/1.73 m2 (95% CI—1.83, 0.46) from baseline to month 48. In female patients, the corresponding mean annualized rate of change during this period was −0.49 (95% CI—2.0, 1.1). In male patients, the mean annualized rate of change was −1.06 (95% CI—2.8, 0.70). These average annualized changes in eGFR with Migalastat represent clinically relevant stabilization of eGFR compared with the annualized declines of −2.6 and −3.0 mL/min/1.73 m2 reported in the literature for 2 large cohorts of untreated male and female patients with Fabry disease. Migalastat was generally safe and well tolerated, with no AE trends attributable to Migalastat. The most common AE reported was mild-to-moderate headache. Few serious AEs were considered related to Migalastat. In patients with Fabry disease and amenable mutations, long-term Migalastat treatment for up to 4.9 years resulted in clinically meaningful stabilization of renal function. This is an encore abstract.
795 - In Vitro Stopcodon Readthrough of Alfa-Galactosidase and Alfa-Glucosidase Premature Termination Codons Using Gentamicin, Geneticin, and Ataluren: Therapeutic Potential for Fabry and Pompe Diseases
Halil Dundar, Gursel Biberoglu, Ilyas Okur, Leyla Tümer, and Fatih Süheyl Ezgü
Gazi University Faculty of Medicine Department of Pediatric Metabolism, Ankara, Turkey
The objective of this study was to investigate in vitro stopcodon readthrough effect of Gentamicin, Geneticin and Ataluren (PTC124) for the treatment of Fabry and Pompe disease caused by Premature Termination Codons (PTCs). The fibroblast cultures of two Fabry patients bearing the p.R220X and p.R227X mutations, respectively, and one Pompe patient bearing p.E888X were treated for 48 h with Gentamicin (250-3000 µg/ml), Geneticin (125-1000 µg/ml) and Ataluren (2.5-20 µM) in Dulbecco’s Modified Eagle Medium (DMEM). The best results were obtained for p.R227X mutation with G418, reaching a 30% and 20% recovery of alfa-galactosidase activity at 125 and 250 µg/ml, respectively while gentamicin at 250 and 500 µg/ml resulted in 10% and 22% recovery, respectively. Furthermore, Ataluren resulted in a 26% recovery at 5 µM for p.R227X. The synthesis of full-length alfa-galactosidase enzyme was demonstrated by western blotting technique upon stopcodon readthrough by Gentamicin, Geneticin and Ataluren. On the other hand, p.R220X mutation did not respond to treatment with Gentamicin, Geneticin and Ataluren possibly because of nonsense mediated decay (NMD), which might impair the readthrough response if a PTC-bearing mRNA is an NMD target. Generally, a purine in the 4th nucleotide position of the termination signal was reported to result in more efficient termination than a pyrimidine, which might explain the difference in response to readthrough treatment between p.R227X and p.R220X mutations. In our study, both p.R227X and p.R220X mutations are of UGA type where the first PTC is followed by A (Adenine) while the second PTC is followed by C (Cytosine). Treatment of the fibroblast culture of Pompe patient bearing p.E888X mutation resulted in 2.5% recovery of alfa-glucosidase activity at 750 µg/mL Gentamicin while Geneticin at 125 µg/mL and Ataluren at 5 µM resulted in 12.5% and 4% recovery of alfa-glucosidase activity, respectively. The synthesis of full-length alfa-glucosidase enzyme was demonstrated by western blotting technique upon stopcodon readthrough by Gentamicin, Geneticin and Ataluren. In summary, this is a proof-of-principle study demonstrating the potential of stopcodon readthrough as a therapeutic strategy for the treatment of Fabry and Pompe diseases caused by PTCs. Measurement of storage materials in lysosomes would also be essential to determine if the level of readthrough is sufficient to restore phenotype to normal or to near to normal.
796 - Response of Patients With Fabry Disease With the Amenable GLA Mutation p.N215 S to Treatment With Migalastat
Ulla Feldt-Rasmussen1, Kathy Nicholls2, Suma P Shankar3, Gere Sunder-Plassmann4, Daniel G Bichet5, Raphael Schiffmann6, Christopher Viereck7, Nina Skuban7, Julie Yu7, Jeffrey Castelli7, Jay A Barth7, and Derralynn Hughes8
1Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
2Royal Melbourne Hospital, Parkville, Australia
3Department of Human Genetics, Emory University School of Medicine, Atlanta, GA, USA
4Division of Nephrology and Dialysis, Department of Medicine Iii, Medical University of Vienna, Vienna, Austria
5Hôpital Du Sacré-Coeur, University of Montreal, Montreal, Canada
6Baylor Research Institute, Dallas, TX, USA
7Amicus Therapeutics, Inc., Cranbury, NJ, USA
8Royal Free Nhs Foundation Trust and University College London, United Kingdom
Fabry disease is an X-linked disorder of lysosomal α-galactosidase A (α-Gal A) deficiency, leading to substrate accumulation and multiorgan disease. Migalastat, an oral pharmacological chaperone, binds to amenable forms of α-Gal A to restore lysosomal trafficking and cellular activity. ATTRACT (Study 012; NCT01218659) is a phase 3, randomized, open-label study comparing Migalastat and enzyme replacement therapy (ERT) in patients previously treated with ERT. Patients were randomized 1.5:1 to continue ERT or receive 150 mg oral Migalastat every other day for 18 months with an option to enter an open-label extension with Migalastat. The study randomized 60 patients with amenable and non-amenable mutations; 57/60 patients received treatment; 53/57 treated patients had amenable mutations. A retrospective subanalysis investigated treatment response at month 18 in patients with p.N215 S, a prevalent mutation associated with the non-classic phenotype. This subanalysis consisted of 8 patients (5 males) in the Migalastat group and 3 patients (1 male) in the ERT group. The average (± 95% CI) age for these patients was 56 (± 7.93) years. In all patients with p.N215 S, baseline left ventricular mass index (LVMi) was 103 ± 26 g/m2; eGFRCKD-EPI was 87.0 ± 13 mL/min/1.73 m2. Seven of eight Migalastat patients and 1/3 ERT patients had LVH at baseline. For the Migalastat group, mean (± 95% CI) change from baseline to month 18 was: eGFRCKD-EPI 0.50 (± 2.55); mGFRiohexol −1.03 (± 3.64); and LVMi −4.80 (± 4.10). Seventy-five percent of patients treated with Migalastat achieved a decrease in LVMi at month 18. Plasma globotriaosylsphingosine (lyso-Gb3) remained stable after the switch from ERT to Migalastat in these patients. The mean (± 95% CI) change from baseline to month 18 for lyso-Gb3 was 0.05 (± 0.79). For the ERT group, mean (± 95% CI) change from baseline to month 18 was: eGFRCKD-EPI −0.77 (± 1.30); mGFRiohexol −4.47 (± 3.57); plasma lyso-Gb3 0.63 (± 1.34); and LVMi 2.47 (± 19.83). Overall, in patients with p.N215 S, there was a consistent decrease in LVMi following 18 months of treatment with Migalastat. This is an encore abstract.
797 - Effects of Treatment With Migalastat on the Combined Endpoint of Kidney Globotriaosylcermide Accumulation and Diarrhea in Patients With Fabry disease: Results From the Phase 3 FACETS Study
Raphael Schiffmann1, Derralynn Hughes2, Daniel G Bichet3, William R Wilcox4, Fred Holdbrook5, Christopher Viereck5, Julie Yu5, Nina Skuban5, Jeffrey Castelli5, Jay Barth5
1Baylor Research Institute, Dallas, TX, USA
2Royal Free Hospital, Nhs Foundation Trust and University College London, London, United Kingdom
3Hôpital Du Sacré-Coeur, University of Montreal, Montreal, Quebec, Canada
4Department of Human Genetics, Emory University, Atlanta, GA, USA
5Amicus Therapeutics, Inc., Cranbury, NJ, USA
Fabry disease is an X-linked disorder of lysosomal α-galactosidase A (α-Gal A) deficiency, leading to substrate accumulation and multiorgan disease. Patients with Fabry disease report gastrointestinal symptoms that significantly impact their quality of life. Migalastat, an oral pharmacological chaperone, binds to amenable forms of α-Gal A to restore lysosomal trafficking and cellular activity. FACETS is a phase 3, double-blind, placebo-controlled study to evaluate Migalastat in patients with Fabry disease with amenable mutations. The study randomized 60 patients; 57/60 patients received treatment; 53/57 treated patients had amenable mutations. A retrospective, unpublished analysis using Xu’s Statistic, designed to evaluate if treatment has an effect on multiple outcomes simultaneously relative to control, assessed changes in kidney interstitial capillary globotriaosylceramide (KIC GL-3) combined with the Gastrointestinal Symptom Rating Scale diarrhea subdomain (GSRS-D). Logistic regression also assessed the correlation between changes in KIC GL-3 and GSRS-D, with a response in KIC GL-3 defined as a reduction of >0.1 inclusions per capillary (above background staining) and response in GSRS-D defined as a reduction >0.33 (above MCID). Eighty-three percent (15/18) of patients with amenable mutations treated with Migalastat demonstrated a response in KIC GL-3 and/or GSRS-D when either or both were elevated at baseline, compared with 33% (5/15) treated with placebo. Xu’s Statistic revealed a significant difference between treatments in the average change from baseline to month 6 for KIC GL-3 (P = .021; 1-sided), GSRS-D (P = .029; 1-sided), and the combined endpoint of KIC GL-3 and GSRS-D (P = .009; 1-sided). Patients with a reduction in KIC GL-3 were 4.3 to 5.6 times more likely to show improvement in GSRS-D than patients who did not have a reduction in KIC GL-3. Overall, reductions in KIC GL-3 are associated with improvements in diarrhea, and Migalastat simultaneously reduces disease substrate and improves gastrointestinal symptoms in patients with Fabry disease with amenable mutations. This is an encore abstract.
798 - Taliglucerase Alfa: Safety and Efficacy Across 6 Clinical Studies in Children and Adults With Gaucher Disease
Ari Zimran1, Michael Wajnrajch2, Betina Hernandez2, and Gregory Pastores3
1Shaare Zedek Medical Center, Hebrew University and Hadassah Medical School, Jerusalem, Israel
2Pfizer Inc., New York, NY, USA
3National Centre for Inherited Metabolic Disorders, Mater Misericordiae University Hospital, Dublin, Ireland
Taliglucerase alfa is an enzyme replacement therapy (ERT) approved for treatment of adult and pediatric patients with Type 1 Gaucher disease (GD) in several countries and the first plant cell–expressed recombinant therapeutic protein approved by the US FDA for humans. We report the findings across 6 key Taliglucerase alfa clinical studies. A total of 33 adult treatment-naïve patients were randomized to Taliglucerase alfa 30 U/kg or 60 U/kg in a 9-month, multicenter, randomized, double-blind, parallel-group, dose-comparison pivotal trial, after which eligible patients continued into 2 consecutive extension trials; 17 treatment-naïve adult patients completed 5 total years of treatment with Taliglucerase alfa. In the only ERT trial focused on exclusively pediatric patients with GD, 11 treatment-naïve children were randomized to Taliglucerase alfa 30 U/kg or 60 U/kg in a 12-month, multicenter, double-blind study; 9 completed 3 total years of treatment in a dedicated pediatric extension study. The effect of switching patients from Imiglucerase to Taliglucerase alfa was also investigated in a separate 9-month trial that included 5 children and 26 adults; 2 children completed a total of 2.75 years and 10 adults completed a total of 3 years of Taliglucerase alfa treatment in the extension studies. All trials evaluated safety and spleen volume, liver volume, platelet count, hemoglobin concentration, and biomarkers as measures of efficacy. Detailed results from baseline through the end of these studies will be presented. Taliglucerase alfa was well tolerated, and adverse events were generally mild/moderate in severity and transient. Treatment with Taliglucerase alfa resulted in improvements (treatment-naïve patients) or stability (patients switched from Imiglucerase) in visceral, hematologic, and biomarker parameters. Together, these comprehensive data support the treatment of adult and pediatric patients with GD who are naïve to ERT or who have previously been treated with Imiglucerase.
799 - Long-Term Safety and Efficacy of Olipudase Alfa in Adults With Acid Sphingomyelinase Deficiency (ASMD)
Ana Cristina Puga1, Melissa Wasserstein2, George Diaz2, Robin Lachmann3, Marie-Hélène Jouvin4, Allena Ji5, and Indrani Nandy4
1Sanofi Genzyme, Chilly-Mazarin, France
2Icahn School of Medicine at Mount Sinai, New York, NY, USA
3National Hospital for Neurology and Neurosurgery, London, United Kingdom
4Sanofi Genzyme, Cambridge, MA, USA
5Sanofi Genzyme, Framingham, MA, USA
800 - Left Ventricular Hypertrophy and Decreased Renal Function at Baseline Predict Worse Cardiovascular and Renal Outcomes in Patients in the FOS Registry
Sandro Feriozzi1, Ales Linhart2, Uma Ramaswami3, Andrey Gurevich4, Alain Joseph4, René Kerstens5, and Derralynn Hughes3
1Belcolle Hospital, Viterbo, Italy
2General University Hospital, Prague, Czech Republic
3Royal Free London Nhs Foundation Trust, University College of London, London, United Kingdom
4Shire, Zug, Switzerland
5Orion Statistical Consulting Bv, Hilvarenbeek, the Netherlands
Fabry disease is an X-linked genetic multisystem disorder. Cardiac and renal involvements are among the most common and detrimental. Heterogeneity in response to enzyme replacement therapy (ERT) suggests that the optimal timing of initiation is not always achieved. Longitudinal data over 15 years in the Fabry Outcome Survey (FOS) facilitates the exploration of long-term outcomes. This analysis focused on data from patients enrolled in FOS who received Agalsidase alfa ERT and who also had available treatment start date, age at diagnosis and values for left ventricular mass index (LVMI) or estimated glomerular filtration rate (eGFR) at ERT initiation. Renal outcomes included dialysis, transplantation, and renal failure. Cardiovascular outcomes included myocardial infarction, left ventricular hypertrophy (LVH), and heart failure. Patients with reported events before ERT initiation were excluded. Time to first renal or cardiovascular event was compared from ERT initiation up to 120 months of treatment in subjects with increased LVMI (>48 g/m2.7 for females, >50 g/m2.7 for males) vs. normal LVMI, and in subjects with reduced eGFR (<90 mL/min/m2) vs. normal eGFR. Kaplan-Meier curves were compared using a log rank test. Cox regression with age at diagnosis as a covariate was used to estimate hazard ratios (HR) between the groups. Evaluation of the effect of LVMI at baseline included 650 and 697 patients for time to first cardiovascular and renal event, respectively. Evaluation of the effect of eGFR at baseline included 1084 and 1147 patients for time to first cardiovascular and renal event, respectively. Patients with LVH demonstrated higher probability of renal (HR = 2.1; 95% confidence interval [CI] 1.57:2.81; log-rank p<0.0001) and cardiovascular events (HR = 2.1; 95% CI 1.61:2.73; log-rank p<0.0001) over the follow-up period. Similarly, patients with reduced renal function demonstrated higher probability of renal (HR = 2.5; 95% CI 2.02:3.12; log-rank p<0.0001) and cardiovascular events (HR = 1.9; 95% CI 1.54:2.25; log-rank p<0.0001) over the follow-up period. Similar statistically significant effects were observed in males and females separately, for both cardiovascular and renal outcomes, with both baselines LVH and decreased renal function. The data show an important interaction between cardiac and renal involvement in Fabry disease. This observation indirectly supports the timely diagnosis and initiation of ERT to prevent negative renal and cardiovascular outcomes.
801 - Analysis of Renal and Cardiac Outcomes in male Fabry Outcome Survey Participants Starting Agalsidase alfa Enzyme Replacement Therapy Before and After 18 Years of Age
Rossella Parini1, Guillem Pintos-Morell2, Julia Hennermann3, Ting-Rong Hsu4, Nesrin Karabul5, Patrick Engrand6, Jörn Schenk7, and Uma Ramaswami8
1Rare Metabolic Diseases Unit, Mbbm Foundation, San Gerardo Hospital, Monza, Italy
2Department of Pediatrics, Germans Trias I Pujol University Hospital, and Research Institute Igtp, Barcelona, Spain
3Villa Metabolica, Department of Pediatric and Adolescent Medicine, University Medical Center, Mainz, Germany
4Department of Pediatrics, Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan
5Department of Neuropaediatric and Inborn Metabolic Disorders, University Children's Hospital, Ruhr, Germany
6Cytel Inc, Geneva, Switzerland
7Shire, Zug, Switzerland
8Royal Free London Nhs Foundation Trust, University College of London, London, United Kingdom
Patients with Fabry disease may have better outcomes when enzyme replacement therapy (ERT) is started early in life. Data from the Fabry Outcome Survey (FOS; data extracted January 2017) were analyzed for males with childhood symptom onset who started Agalsidase alfa ERT at ≤18 years old (child treated males, CTM; n = 141), >18 and ≤30 years old (young adult treated males, YTM; n = 220), and >30 years old (adult treated males, ATM; n = 483). The following renal and cardiac outcomes were analyzed up to 10 years after ERT initiation: estimated glomerular filtration rate (eGFR), proteinuria, and left ventricular mass indexed to height (LVMI). Mean age (SD) at symptom onset was similar for the 3 groups: 7.4 (3.7) years for CTM, 8.7 (4.4) years for YTM, and 8.9 (3.7) years for ATM. Mean age (SD) at diagnosis was 10.4 (4.7) years for CTM, 18.6 (6.5) years for YTM, and 35.8 (15.9) years for ATM, and mean (SD) age at ERT initiation was 13.0 (3.8) years, 24.0 (3.5) years, and 44.9 (10.4) years, respectively. Mean (SD) FOS-Mainz Severity Score Index at baseline was 10.0 (7.3) for CTM, 13.6 (8.5) for YTM, and 19.9 (11.6) for ATM. Mean (SD) eGFR at baseline was 113.5 (27.5) mL/min/1.73m2 for CTM, 120.3 (20.7) mL/min/1.73m2 for YTM, and 89.7 (27.7) mL/min/1.73m2 for ATM, and the median (IQR) of the overall mean change per year over 10 years was +1.8 (−3.4;+8.1) mL/min/1.73m2, −1.0 (−4.1;+1.5) mL/min/1.73m2, and −1.9 (−4.9;+0.2) mL/min/1.73m2, respectively. Median (IQR) proteinuria at baseline was 83.6 (27.0;142.4) mg/day for CTM, 140.0 (60.0;230.0) mg/day for YTM, and 337.3 (130.0;815.0) mg/day for ATM and the median (IQR) of the overall mean change per year over 10 years was +5.0 (−1.2;+16.8) mg/day, +0.5 (−5.2;+20.1) mg/day, and +5.4 (−18.9;+61.2) mg/day, respectively. Mean (SD) LVMI at baseline was 37.4 (8.2) g/m2.7 for CTM, 40.6 (10.2) g/m2.7 for YTM, and 58.2 (18.4) g/m2.7 for ATM, and the median (IQR) of the overall mean change per year over 10 years was −2.3 (−4.9;0.9) g/m2.7, −0.2 (−2.9;1.5) g/m2.7, and −0.6 (−4.3;3.0) g/m2.7, respectively. These data show that initiating ERT in childhood, before manifestation of severe symptoms, may attenuate progressive Fabry-related renal and cardiac disease, and that initiating ERT in adulthood, when renal and cardiac involvement is already apparent, may stabilize eGFR and LVMI progression. The results from this analysis suggest that greater clinical benefits may be obtained the earlier ERT is started.
802 - Profile of Patients With Mucopolysaccharidosis Type II Without Cognitive Impairment Who Started Idursulfase Treatment Aged >20 Years: Data on late Treatment Start From The Hunter Outcome Survey (HOS)
Heather Lau1, Julia Hennermann2, Nathalie Guffon3, Shuan-Pei Lin4, Virginie Jego5, and David Whiteman6
1Division of Neurogenetics, New York University School of Medicine, New York, NY, USA
2Villa Metabolica, Department of Pediatric and Adolescent Medicine, University Medical Center, Mainz, Germany
3Centre de Référence Des Maladies Héréditaires Du Métabolisme, Hôpital Femme Mère Enfants, Bron, France
4Department of Pediatrics, Mackay Memorial Hospital and Mackay Medical College, Taipei, Taiwan
5Cytel, Inc., Geneva, Switzerland
6Shire, Lexington, MA, USA
Mucopolysaccharidosis type II (MPS II; Hunter syndrome) is a progressive X-linked disease caused by deficient activity of iduronate-2-sulfatase (I2 S). The so-called attenuated (slowly progressive) form has minimal CNS involvement; however, extra-neurologic manifestations can be as significant as in the severe (early progressive) form. Enzyme replacement therapy with recombinant I2 S (Idursulfase; Shire, Lexington, MA, USA) was available in 2006 in the USA, 2007 in the EU, and subsequently in other countries globally. Herein, we describe patients with MPS II without cognitive impairment from the Hunter Outcome Survey (HOS; a global observational registry) who were aged >20 years at treatment initiation. Exclusion of patients with cognitive impairment was based on the answer to the yes/no question from the database: “Cognitive impairment?”. As of March 2016, 59/947 patients followed prospectively in the registry met these criteria. Patients were stratified by age at treatment start: >20 to <25 years (n = 21), ≥25 to <30 years (n = 18), ≥30 to <35 years (n = 7), and ≥35 years (n = 13). Retrospective analyses of median ages at symptom onset in years (P10; P90) were: 3.3 (0.8; 8.0), 3.5 (0.2; 7.5), 4.8 (4.1; 18.2), and 4.0 (1.0; 44.3), respectively. Overall, the systems most commonly affected (between birth and last visit) were musculoskeletal (59/59), abdominal/gastrointestinal (57/59), and ear (56/58). Median ages at diagnosis were: 7.2 (0.3; 19.0), 4.6 (2.9; 26.0), 18.8 (4.5; 32.6) and 7.5 (4.0; 19.0). Median ages at treatment initiation were: 22.5 (20.6; 24.8), 27.7 (25.2; 29.2), 31.9 (30.4; 34.2), and 39.3 (36.7; 47.8). Reasons for delaying treatment initiation after diagnosis are unknown. Apart from drug availability, factors may include mild clinical symptoms, physician/patient decision or perception of inefficacy after a certain age, balancing infusion regimens with daily life, or onset or worsening of symptoms. Further analysis is required to delineate these barriers and raise awareness of the importance of early diagnosis and timely treatment initiation. Previously presented at WORLDSymposium 2017.
803 - Nurse Led Administration of an Intracerebroventricular (ICV) Medication
Laura Lee, Mathilda Antonini, and Mel Mcsweeney
Great Ormond Street Hospital, London, United Kingdom
804 - Toward Establishment of a Minimal Clinically Important Difference in the Treatment of Alpha-Mannosidosis: First Results From Velmanase alfa (Human Recombinant Alpha-Mannosidase) Development Program
Paul Harmatz1, Federica Cattaneo2, Diego Ardigò2, Silvia Geraci2, Allan Melgaard Lund3, and Line Borgwardt3
1UCSF Benioff Children’s Hospital Oakland, Oakland, CA, USA
2Chiesi Farmaceutici S.P.A., Parma, Italy
3Centre for Inherited Metabolic Diseases, Copenhagen University Hospital Righospitalet, Copenhagen, Denmark
Velmanase alfa (human recombinant alpha-mannosidase) is the first enzyme replacement therapy in development for the treatment of alpha-mannosidosis (AM). All 33 patients treated during clinical development were evaluated in a long-term follow-up (rhLAMAN10) study with a mean (SD) exposure of 29.3 (15.2) months; 10 of the 33 patients were exposed to an initial placebo period of 12 months before switching to active treatment. AM is a multisystem lysosomal storage disorder, presenting with heterogeneous severity, and large variability in terms of age of onset and manifestations. In this context, a single outcome measure does not provide the adequate sensitivity to quantify clinically meaningful treatment effect in a comprehensive way. The aggregation of multiple disease-specific domains has been proposed to overcome this issue, generating a clinically relevant overall treatment response. End points measured during the study were grouped into 3 domains defined as pharmacodynamics (reduction of serum oligosaccharides), functional (Three Minutes Stair Climb Test (3MSCT), Six Minute’s Walk Test (6MWT), and Forced Vital Capacity (FVC) % predicted), and quality of life (Childhood Health Assessment Questionnaire (CHAQ) Disability Index (DI) and CHAQ pain). Responders were evaluated based on Minimal Clinically Important Difference (MCID) thresholds established in proxy-diseases. Adopted MCID were oligosaccharides below 4 µmol/L, increase of 7 steps/minute for 3MSCT (proxy: MPS IV A), increase of 30 meters for 6MWT (proxy: Pompe disease), increase of 10% for FVC (proxy: Pompe disease), decrease of 0.13 for CHAQ DI (proxy: Juvenile Arthritis) and of 8.2% for CHAQ pain (as in pediatric rheumatology). Patients were considered responders in one domain if the MCID was achieved in at least one parameter of the domain; responders to treatment were defined as patients with response in at least 2 domains. Based on these criteria, response to treatment was observed in 88% (29/33) of patients treated with Velmanase alfa; response during placebo phase was reported in 33% (3/10). Response in all 3 domains was achieved in 45% of treated patients versus 0% during placebo. This analysis represents the first attempt to establish an AM-specific disease score based on MCIDs for key outcome measures. The above reported results provide evidence of the clinical benefit of Velmanase alfa therapy in AM patients, highlighting its disease-modifying effect.
805 - Impact of Anti-Drug Antibodies (ADA) on Safety and Efficacy of Velmanase Alfa (Human Recombinant Alpha-Mannosidase) Long-Term Enzyme Replacement Therapy in Patients With Alpha-Mannosidosis
Line Borgwardt1, Nathalie Guffon2, Yasmina Amraoui3, Linda de Meirleir4, Mercedes Gil-Campos5, Jens Fogh6, Allan Melgaard Lund1, Hannerieke Van Den Hout7, Frits Wijburg8, Nicole Muschol9, Anna Tylki-Szymanska10, Silvia Geraci11, Federica Cattaneo11, and Diego Ardigò11
1Centre for Inherited Metabolic Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
2Centre de Référence Des Maladies Héréditaires Du Métabolisme, Hôpital Femme Mère Enfant, Lyon, France
3Johannes Gutenberg-University Medical Center Mainz, Center For Pediatric and Adolescence Medicine, Mainz, Germany
4Paediatric Neurology and Metabolism, Universitair Ziekenhuis, Brussels, Belgium
5Unidad de Metabolismo e Investigación Pediátrica. Hospital Universitario Reina Sofía, Imibic, Cordoba, Spain
6Zymenex A/S, Hillerød, Denmark
7Pompe Center and Center for Lysosomal and Metabolic Diseases, Erasmus Mc University Medical Center, Rotterdam, the Netherlands
8Academic Medical Centre, Amsterdam, the Netherlands
9International Center for Lysosomal Disorders, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
10Department of Paediatric, Nutrition and Metabolic Diseases, The Children’s Memorial Health Institute, Warsaw, Poland
11Chiesi Farmaceutici S.P.A., Parma, Italy
Patient immune response to a therapeutic protein (either pre-existing or developed during treatment) can significantly impact its safety and efficacy profile. Velmanase alfa is an enzyme replacement therapy in development for the treatment of alpha-Mannosidosis, an ultra-rare lysosomal storage disorder. In the clinical studies and after-trial treatment programs, 33 patients have been treated with a mean (SD) total exposure of 29.3 (15.2) months. Patients were tested for anti-drug antibodies (ADA) before and during treatment and defined ADA positive (ADA+) if at least one titer was above the lower limit of detection (1.4 U/mL). Global therapeutic response (GTR) was evaluated as improvements exceeding the Minimal Clinically Important Difference in at least one end point of at least 2 of the following domains: pharmacodynamics (serum oligosaccharides), functional (3 Minutes Stair Climbing Test, 6 Minutes Walking Test, Forced Vital Capacity), and quality of life (Childhood Health Assessment Questionnaire’s Disability Index and VAS pain). In total, 8 patients were ADA+ before (preADA+) and 3 developed ADA during treatment only (txADA+). Infusion related reactions occurred in 2 of the 3 txADA+ patients (and none of the preADA+), and all resolved without sequelae or therapy discontinuation. One patient dropped out of phase II study after IRR events, but he was subsequently enrolled in the phase III trial; he is still receiving infusions of Velmanase alfa. One serious adverse event (acute renal failure) occurred in a preADA+ patient and was considered “possibly related,” although additional potential causal factors were also present (i.e., high dose NSAIDs and dehydration). The event was moderate in intensity and the patient recovered without sequelae. GTR under treatment was achieved in 85.7% (6/7) of the preADA+ and 66.7% (2/3) of the txADA+ patients, in comparison with the 91.8% (21/23) of the ADA negative subjects. Thus, pre-existing ADA do not seem to affect therapeutic response to velmanase alfa. Similarly, the development of ADA during treatment was not associated with significant adverse reactions and 2 out of 3 txADA+ patients maintained a sustained positive clinical response. In conclusion, based on the currently available data, ADA do not appear to be a major concern for the clinical use of Velmanase alfa.
806 - Improvements in Endurance, Serum Immunoglobulin G Levels, and Quality of Life in Alpha-Mannosidosis Patients Switching From Placebo to Velmanase Alfa Long-Term Enzyme Replacement Therapy
Nathalie Guffon1, Yasmina Amraoui2, Federica Cattaneo3, Diego Ardigò3, Silvia Geraci3, Mercedes Gil-Campos4, Linda de Meirleir5, Hannerieke Van Den Hout6, Simon Jones7, Allan Melgaard Lund8, and Line Borgwardt8
1Centre de Référence Des Maladies Héréditaires Du Métabolisme, Hôpital Femme Mère Enfant, Lyon, France
2Gutenberg-University Medical Center Mainz, Center for Pediatric and Adolescence Medicine, Mainz, Germany
3Chiesi Farmaceutici S.P.A., Parma, Italy
4Unidad de Metabolismo e Investigación Pediátrica. Hospital Reina Sofía, Cordoba, Spain
5Paediatric Neurology and Metabolism, Universitair Ziekenhuis, Brussels, Belgium
6Pompe Center and Center for Lysosomal and Metabolic Diseases, Erasmus Mc University Medical Center, Rotterdam, the Netherlands
7Manchester Centre for Genomic Medicine, Central Manchester University Hospitals Nhs Foundation Trust, Manchester, United Kingdom
8Centre for Inherited Metabolic Disorders, Copenhagen University Hospital, Righospitalet, Copenhagen, Denmark
Velmanase alfa is the first human recombinant form of alpha-mannosidase in development as long-term enzyme replacement therapy for alpha-mannosidosis. Relevant information on efficacy of investigational drugs can be obtained by analyzing the placebo patients after switch to active treatment at the end of development trials. In the 12-month, phase III, rhLAMAN-05 trial, 10 patients (5 adults and 5 pediatrics) were allocated to placebo. At trial conclusion, all patients switched to Velmanase alfa in compassionate use or trial extensions, and 12-18 months data after the start of active treatment were collected in a comprehensive evaluation visit (last observation; LO). Results are presented as mean absolute values (SD) or mean relative changes (SD) versus baseline after 12 months of placebo (n = 10) and at LO during active treatment (n = 9). Endurance was measured by the Three Minutes Stair Climb Test (3MSCT) and the Six Minute Walk Test (6MWT), with average baseline performances of 55.5 (16.0) steps/minute and 465.7 (140.5) meters, respectively. During the 12 months of placebo treatment, patients decreased by −3.6% (13.5) and −0.8% (10.8) in the 3MSCT and 6MWT, respectively. At LO, the 3MSCT improved by 9.0% (25.1) and the 6MWT by 2.2% (13.1). Improvements were consistently observed in both pediatric and adult patients. Recurrent infections and immunological impairment are key features of the disease, especially in pediatric patients. Serum immunoglobulin class G (IgG) levels were 7.27 g/L (1.64) at baseline. During the placebo period levels remained stable compared to baseline (+1.0% (16.9)), while a marked increase was observed following Velmanase alfa treatment by +37.3% (16.1) vs baseline at LO. Patient’s quality of life was assessed via the Childhood Health Assessment Questionnaire (CHAQ) that allows the evaluation of both patient disability and discomfort (pain). The disability index (DI) was equal to 1.56 (0.67) at baseline, increased (worsened) to 1.71 (0.50) after 12 months placebo treatment, and improved (decreased) to 1.43 (0.50) at LO; pain worsened during the placebo phase from 0.42 (0.59) to 0.52 (0.66) and improved to 0.36 (0.51) at LO. Results of the comparison between the placebo phase and the treatment with Velmanase alfa in the same patients provide evidence of a beneficial effects of the enzyme replacement on serum IgG levels and on an array of clinically-relevant domains, including mobility, endurance, pain, and quality of life.
807 - Impact of Elosulfase Alfa Treatment on Patient-Reported Outcomes in Morquio A Syndrome: Results From the First Year of an English Managed Access Agreement
Christine Lavery1, Simon Jones2, Derralynn Hughes3, Elaine Murphy4, Ana Jovanovic5, Christian Hendriksz6, Maureen Cleary7, Tarekegn Hiwot8, and Suresh Vijayaraghavan9
1Society for Mucopolysaccharide Diseases, Amersham, United Kingdom
2University of Manchester, Manchester, United Kingdom
3Royal Free London Nhs Ft and Uc, London, United Kingdom
4National Hospital for Neurology and Neurosurgery, London, United Kingdom
5Salford Royal Nhs Foundation Trust, Salford, United Kingdom
6University of Pretoria, Pretoria, South Africa
7Great Ormond Street Hospital, London, United Kingdom
8New Queen Elizabeth Hospital, Birmingham, United Kingdom
9Birmingham Children's Hospital, Birmingham, United Kingdom
808 - Enhanced PK Profile of Pegunigalsidase Alfa Supports Once-Monthly Dosing of 2 mg/kg of Pegunigalsidase Alfa (PRX-102) for the Treatment of Fabry Disease
Einat Brill-Almon1, Martha R. Charney2, Derralynn Hughes3, Raphael Schiffmann4, David G. Warnock5, Sari Alon1, and Raul Chertkoff1
1Protalix, Carmiel, Israel
2Pharmacokinetics Consultant, Toronto, Canada
3Lsdu, Institute of Immunity and Transplantation, Royal Free London Nhs Foundation Trust, London, United Kingdom
4Baylor Institute of Metabolic Diseases, Baylor University Medical Center, Dallas, TX, USA
5University of Alabama at Birmingham, Department of Medicine, Birmingham AL, USA
Pegunigalsidase alfa (PRX-102), a novel PEGylated Enzyme Replacement Therapy (ERT) for Fabry disease (FD) was administrated IV every other week (EOW) to FD patients as part of a Phase 1/2 study, in three dose cohorts (0.2, 1.0, and 2.0 mg/kg). Pegunigalsidase alfa was found to be safe and well tolerated and demonstrated effectiveness in various disease parameters. The pharmacokinetic (PK) parameters of pegunigalsidase alfa are markedly improved compared to the two currently marketed ERT drugs for FD. The half-life of pegunigalsidase alfa is ∼ 80 hours vs. ∼2 hours of Agalsidase alfa and Agalsidase beta with Cmax of the 2mg/kg cohort ∼10-fold higher than those published for Agalsidase beta.
809 - Biochemical Correction Associated With Improved Muscle Function in a Phase I/II Clinical Trial of Clenbuterol in Pompe Disease Patients Stably Treated With ERT
Dwight Koeberl, Laura Case, Edward Smith, Crista Walters, Christoph Hornik, Deeksha Bali, and Priya Kishnani
Duke University, Durham, NC, USA
810-The Nurse’s Role in the Multidisciplinary Management of Patients on Enzyme Replacement Therapy
Maria Normoyle
Royal Children’s Hospital, Melbourne, Australia
Enzyme replacement therapy (ERT) is a mode of therapy that provides an artificially manufactured enzyme to replace the deficient enzyme in Mucopolysaccharidoses (MPS) types I, II, and VI, Fabry-, Pompe- and Gaucher- diseases. It has been approved and funded in many countries for over a decade. ERT has been approved in Australia for these disorders for approximately 10 years and is funded by the Australian Federal Government under a special scheme: the Life Saving Drugs Program (LSDP). In order to access treatment, applications are submitted to the LSDP based on strict clinical, laboratory and diagnostic (e.g., mutation analysis) criteria. Continuation of the treatment is dependent on clinical and laboratory outcome measures presented to LSDP yearly. Patients require annual assessments by a large number of subspecialists. ERT is time consuming; it requires the patient and family to attend the hospital regularly for intravenous infusions and for specialists’ appointments to monitor treatment effectiveness. In 2015, 11 patients were treated with ERT at the Royal Children’s Hospital in Melbourne: seven with MPS type I, II, and VI, two with Pompe disease, one with Fabry disease and one with Gaucher disease. In 2017, ERT is administered to 16 patients: 12 with MPS I, II, VI, two with Pompe disease, one with Fabry disease and one with Gaucher disease. A patient on ERT treatment may need to come to hospital weekly or fortnightly for IV treatment and have 10-48 sub-speciality face-to-face encounters (April 2016- April 2017 data). The Nurse acts as a liaison between the family, the clinical teams, community health services and LSDP. Within the hospital environment the Nurse co-ordinates multidisciplinary care including sub specialties, the admissions manager, Day Medical Unit staff, Pharmacy, hospital school and the family to ensure seamless appointments and treatments. The Nurse builds a strong working relationship with the family by regular meetings and phone calls. The Nurse offers support in order to foster communication and compliance. Not least, the Nurse must consider the child’s quality of life and works with the family to facilitate the best outcome possible. Given the increase in the number of patients and predicted increase in the number of disorders for which ERT will be available, the nurse’s role has become pivotal to maintaining the quality assurance of the treatment.
811 - ZFN-Mediated In Vivo Genome Editing Results in Therapeutic Levels of Alpha Galactosidase A and Effective Substrate Reduction in a Murine Model for Fabry Disease
Marshall Huston1, Makiko Yasuda2, Silvere Pagant2, Susan St. Martin1, Scott Sproul1, Russell Dekelver1, Kathleen Meyer1, Michael Holmes1, Thomas Wechsler1, and Robert Desnick3
1Sangamo Therapeutics, Richmond, CA, USA
2Icahn School of Medicine at Mount Sinai, New York, NY, USA
3Icahn School of Medicine at Mount Sinai, Richmond, CA, USA
Fabry disease (FD) is an X-linked lysosomal storage disease caused by mutations in the GLA gene encoding alpha galactosidase A (α-GalA). FD is characterized by progressive systemic accumulation of α-GalA’s substrates, globotriaosylceramide (Gb3) and lyso-Gb3, leading to renal, cardiac, and/or cerebrovascular disease and culminating in premature demise. The mutation and any residual α-GalA enzyme level determine whether the disease presents as classic early onset FD or as one of the later onset variants. FD is treated by enzyme replacement therapy (ERT) via lifelong biweekly infusions, which often create hardship for patients, and can yield variable results. Thus, an improved, more effective, and long-lasting treatment is needed. The presented strategy (currently in clinical studies for Hemophilia B and Mucopolysaccharidoses type I and II) uses Zinc-Finger Nuclease (ZFN)-mediated genome editing to permanently integrate a corrective hGLA gene in the Albumin locus in liver cells. This approach ensures long-term expression of the transgene by exploiting the high level transcriptional activity of the native Albumin enhancer/promoter in stably modified hepatocytes. This genome editing approach was tested in a mouse model (GLAKO) lacking α-GalA activity and containing high levels of Gb3/lyso-Gb3 in plasma and tissues. GLAKO mice were treated with a single injection of an AAV hGLA donor in the presence of Albumin-targeted AAV ZFNs under the control of a liver-specific promoter. Administration of the three AAV vectors achieved supraphysiological levels of up to 50× of WT of α-GalA activity in plasma (sustained for 2 month study duration) and high activity levels in liver, heart, kidney and spleen. Gb3 in these tissues averaged <10% of that measured in untreated GLAKO mice. Importantly, appropriate glycosylation of the α-GalA enzyme was confirmed to ensure efficient lysosomal uptake in target tissues. In follow-up studies, further improvements to the hGLA donor construct utilizing alternate signal peptides resulted in a-GalA activity levels of up to 250x of WT with near complete clearance of Gb3/Lyso-Gb3 storage material in target tissues. Thus “proof-of-concept” for use of AAV-mediated genome editing of hepatocytes to express therapeutic levels of human α-GalA has been demonstrated. A marked reduction of pathological accumulated Gb3/lyso-Gb3 in key tissue sites was found, further supporting our liver-based AAV approaches as potential therapies for FD.
812 - Liver-Based Expression of the Human Alpha-Galactosidase A Gene in a Murine Fabry Disease Model Results in Continuous Therapeutic Levels of Enzyme Activity and Effective Substrate Reduction
Thomas Wechsler1, Marshall Huston1, Makiko Yasuda2, Silvere Pagant2, Susan St. Martin1, Russell Dekelver1, Kathleen Meyer1, Robert Desnick2, and Michael Holmes1
1Sangamo Therapeutics, Richmond, CA, USA
2Icahn School of Medicine at Mount Sinai, New York, NY, USA
Fabry disease (FD) is an X-linked lysosomal storage disease caused by mutations in the GLA gene encoding alpha galactosidase A (α-GalA), which acts on globotriaosylceramide (Gb3) and its deacylated version lyso-Gb3. The progressive systemic accumulation of these substrates leads to renal, cardiac, and/or cerebrovascular disease in adulthood and can result in premature demise. The mutation and any residual α-GalA enzyme level determine whether the disease presents as classic early onset FD or as one of the later onset phenotypes. FD is treated by enzyme replacement therapy (ERT), however the short half-life of the enzyme necessitates lifelong biweekly infusions, with variable results. An improved, more effective, and long-lasting treatment would benefit FD patients. An AAV-mediated, liver-targeted gene therapy was evaluated in a mouse model (GLAKO) that lacks α-GalA activity, resulting in high levels of Gb3/lyso-Gb3 in plasma and tissues. This strategy employs an episomal AAV vector encoding human GLA cDNA (hGLA) driven by a liver-specific promoter. Vector administration in GLAKO mice led to supraphysiological plasma α-GalA levels (up to 200-fold of WT at some doses) at day 14 sustained continuously for up to 2 months. At study end, dose-dependent α-GalA activity was increased in liver, heart, kidney, and spleen with a corresponding reduction of Gb3/lyso-Gb3 to near-normal levels. In a follow-up 6-month dose finding study in GLAKO mice, where six different doses of AAV hGLA cDNA were tested, it was found that expression of α-GalA (up to 30-fold of WT) was stable up to 6 months and well tolerated in these animals. Data for tissue uptake and Gb3/Lyso-Gb3 clearance at study end will be presented. Importantly, appropriate glycosylation of the α-GalA enzyme produced from liver cells was confirmed by in vitro and in vivo experiments to ensure efficient mannose-6-phosphate mediated lysosomal uptake in target tissues. Thus “proof-of-concept” for the use of AAV-mediated targeting of hepatocytes to express therapeutic levels of human α-GalA has been demonstrated. A marked reduction of the pathological accumulated Gb3/lyso-Gb3 in key tissue sites was found, further supporting this liver-based AAV hGLA cDNA approach as a potential therapy for FD.
813 - Enzyme Replacement Therapy Infusion Related Reactions: A Single-Center review of Incidence and Management in Children With Lysosomal Storage Disorders
Caroline Hart, Marie White, Sindisiwe Mnkandla, Chin Gan, Maureen Cleary, and James Davison
Great Ormond Street Hospital, London, United Kingdom
W) Glycosylation Disorders/CDG, Protein Modification Disorders (814 to 831)
814 - The Patient Diagnosed With Congenital Glycosylation Defect as a Refugee: Her Life is a Novel
Isil Ozer
19 Mayis University, Samsun, Turkey
815 - A 20-Years Follow-Up of a Case of Congenital Disorder of Glycosylation Type 1b
Karolina Stepien and Christian Hendriksz
Adult Inherited Metabolic Disorders, Salford Royal Nhs Foundation Trust, Salford, Great Britain
Congenital Disorder of Glycosylation (CDG) 1b is a rare metabolic disorder caused by phosphomannose isomerase activity and presents in childhood primarily with gastro-intestinal and hepatic symptoms. The condition responds to oral mannose treatment. We present a case of 20-year old female patient, homozygous for the D131 N mutation in the phosphomannose isomerase (PM1) gene that was in keeping with reduced phosphomannomutase isomerase activity. Her Carbohydrate Deficient Transferrin was 16.8% (0-2.6). The diagnosis was made when she was 6-months of age after she presented with hypoglycemia during the episodes of diarrhea and vomiting and was associated with hyperinsulinism. She had hepatomegaly and gastrointestinal symptoms without neurological signs. Thrombotic tendency screen returned to normal within 10 days of commencing mannose and over the next five months her transferrin pattern also improved. There were no significant health problems throughout her childhood and teenage years. At the age of 20, her liver function tests were normal with normal clotting; Protein C was 99 µ/dL (70-140) and protein S 96 (53-123 µ/dL). Her glucose was 4.3 mmol/L after prolonged fasting of 59 hours. Due to poor compliance to mannose, the treatment was stopped and she has remained off mannose for three years now. She reports occasional loose stools that occur infrequently. Bilateral diffuse osteochondritis dissecans, significantly limiting her mobility, remained the main concern. She underwent two surgical procedures under general anesthetics. Six months later an USS of her knees showed osteophyte reoccurrence. She followed emergency regimen during peri-operative period to prevent hypoglycemia more than to treat it. In conclusion, CDG 1b is a treatable condition. Our patient seems to have grown out of the disease and is well despite no mannose administration. Enchondromatosis has been described in O-linked, but not in N-linked disorders of glycosylation. We report the first case of CDG1b with features similar to Ollier disease affecting her knees with no clear association between these two conditions.
816 - Improvement of Glycosylation Abnormalities in a Severely Affected Patient With SLC39A8 Deficiency and Mitochondrial Dysfunction
Francesca Moore1, Lisa Riley2, John Christodoulou3, and Shanti Balasubramaniam3
1Nsw Biochemical Genetics Service, The Children's Hospital at Westmead, Sydney, Australia
2Genetic Metabolic Disorders Research Unit, Western Sydney Genetics Program, The Children's Hospital, Sydney, Australia
3Western Sydney Genetics Program, The Children's Hospital at Westmead, Sydney, Australia
The SLC39A8 gene encodes a ubiquitously expressed, transmembrane manganese (Mn) and zinc (Zn) transporter which localizes to both cell and mitochondrial membranes. Mn and Zn are essential trace elements and cofactors for multiple biological processes including energy metabolism, neurodevelopment, blood clotting, immunological response, endocrine regulation, bone, and connective tissue growth. Due to the abundance of Mn- and Zn-dependent processes, SLC39A8 transporter deficiency has been associated with a severe multisystemic developmental disorder. Decreased serum Mn concentrations impair the function of β-galatosyltransferase that transfers UDP-galactose to N-acetylglucosamine of a glycan, resulting in reduced glycosylation and type II congenital disorders of glycosylation. Increasing the intracellular UDP-galactose pool by galactose and uridine supplementation completely restored galactosylation in a severely affected patient (Park et al 2015). Here, we describe a recently reported 13-year-old female with SLC39A8 deficiency, a primary disorder of Mn transport with secondary glycosylation abnormalities and mitochondrial dysfunction displaying profound psychomotor retardation, dystonia, seizures, failure to thrive, and bilateral basal ganglia hyperintensities on T2-weighted imaging and cerebral atrophy (Riley et al J Inherit Metab Dis. 2017). Initial supplementation with oral galactose and uridine, with subsequent addition of Mn led to significant improvement and transient normalization of the transferrin isoform pattern with clinically correlated reductions in dystonia, tremors, and improved attentiveness. It remains to be established whether introduction of these therapies early in the clinical course of the disease would have an ameliorating effect on disease progression.
817 - N-Acetylmannosamine (ManNAc) for the Treatment of GNE Myopathy: 18-Month Preliminary Results From a Phase 2 Open-Label Study
Nuria Carrillo1, Marjan Huizing1, Melanie Quintana2, Christina Slota3, Bradley Class1, Petcharat Leoyklang1, Ashleigh Glowacki1, Kennan Bradley1, Carla Ciccone1, John Perreault1, May Christine Malicdan1, Hootan Khatami4, and William A. Gahl1
1NIH, Bethesda, MD, USA
2Berry Consultants, Austin, TX, USA
3RTI, Research Triangle Park, NC, USA
4Escala Bio, New York City, NY, USA
818 - CGD Type Ib Patient Diagnosed due to Hypoglycemia and Elevated Liver Function Tests
Pinar Haznedar1 and F. Tuba Eminoglu2
1Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
2Department of Pediatrics, Division Pediatric Metabolism, Ankara University Faculty of Medicine, Ankara, Turkey
819 - A 10-Year Research Program on Congenital Disorders of Glycosylation in Argentina
Carla Asteggiano1, Magalí Papazoglu2, María Beatríz Bistué Millón2, Nydia Azar3, Norma Spécola4, Norberto Guelbert5, Niels Suldrup6, Marcela Pereyra7, María Fernanda Peralta3, and Raquel Dodelson de Kremer3
1Conicet, Centro de Estudio de Las Metabolopatías Congénitas, Hospital de Niños.Sma Trinida Unc/Ucc, Córdoba, Argentina
2Conicet, Centro de Estudio de Las Metabolopatías Congénitas, Hospital de Niños.Sma Trinidad Unc, Córdoba, Argentina
3Centro de Estudio de Las Metabolopatías Congénitas, Hospital de Niños.Sma Trinidad Unc, Córdoba, Argentina
4Unidad de Metabolismo, Hospital de Niños de La Plata, La Plata, Argentina
5Sección Enfermedades Metabólicas, Hospital de Niños.Sma Trinidad, Córdoba, Argentina
6Laboratorio de Análisis Clínicos Iaca, Bahía Blanca, Argentina
7Servicio de Pediatría, Hospital Notti, Mendoza, Argentina
Defects in the N-glycosylation pathway include more than 110 affected genes, and they are responsible for Congenital Disorders of Glycosylation (CDG) an inherited metabolic disease. Protein hypoglycosylation caused a clinical multisystem phenotype ranging from mild to severe that leads the diagnosis in a very challenging way.
820 - Exome Sequencing for the Clinical Diagnosis of Non-Progressive Hepatic Form of Glycogen Storage Disease IV
Jose Maria Satizabal Soto1, Lina Johanna Moreno Giraldo2, Adalberto Sanchez1
1Universidad Del Valle -, Cali, Colombia
2Universidad Del Valle, Universidad Santiago de Cali, Cali, Colombia
Glycogen storage disease type IV-(GSDIV) is caused by homozygous or compound heterozygous mutation in the GBE1 gene, which encodes the glycogen branching enzyme, on chromosome 3p12. GSDIV is a clinically heterogeneous disorder. The typical “classic” hepatic presentation is liver disease of childhood, progressing to lethal cirrhosis. The neuromuscular presentation of GSDIV is distinguished by age at onset into 4 groups: Perinatal, presenting the fetal akinesia deformation sequence and perinatal death; Congenital, with hypotonia, neuronal involvement, and death in early infancy; Childhood, with myopathy or cardiomyopathy; and Adult, with isolated myopathy or adult polyglucosan body disease. The enzyme deficiency results in tissue accumulation of abnormal glycogen with fewer branching points and longer outer branches, resembling an amylopectin-like structure, also known as polyglucosan. 2-year-old female patient with history of congenital hypothyroidism, global neuro-developmental delay, hypotonia, failure to grow, with metabolic studies: negative urine screening, negative amino acid chromatography, normal karyotype, cerebral magnetic resonance imaging showing mild atrophy cerebral, dysmorphic features without hepatic or cardiac involvement. Non-consanguinity is reported between parents, and no previously family history for this disease. Exome sequencing was performed on the Illumina platform, showing single nucleotide variant (G >A) on gene GBE1, located on chromosome-3 (rs80338672), with heterozygous inheritance mode, reported as missense, and previously associated with pathogenicity. Non-progressive hepatic form is less frequent, Burrow et al (2006) reported a 30-month-old girl with GSD4 who had stable congenital hypotonia with gross motor delay and severe fibro fatty replacement of the musculature, but no hepatic or cardiac involvement. It suggested that the unusually mild phenotype in this patient might be due to residual enzyme activity.
821 - Congenital Disorder of Glycosylation—Phosphomannomutase 2 Deficiency (CDG-PMM2/ CDG IA): Follow Up Findings in a 32-year-old Argentinian Patient
Marina Szlago1 and Lidia Caceres2
1Consultorio Neuropediatría. Errores Congenitos Del Metabolismo, Caba, Argentina
2Consultorio Neuropediatría, Caba, Argentina
CDG-pmm2/cdg1a is mainly characterized by a multisystemic age-related clinical manifestations including failure to thrive, hypotonia, developmental delay, strabismus, cerebellar hypoplasia, inverted nipples and fat pads. A 32-year-old female patient. She presented low APGAR score, hypotonia, feeding difficulties, low weight, strabismus, and fat pads noticed in the first months of life. After the first year, delayed developmental was evident and also ataxic gait, lower extremities hypotrophy, stroke like episodes (2) deep venous thrombosis, amenorrhea, cataracts, hypothyroidism, and supra renal insufficiency. MRI showed a progressive cerebellar atrophy. In the last year a thyroid neoplasia was detected and removed. Nowadays, she is a happy and friendly girl. The screening test of CDG was performed by Dr. Nestor Chamoles who suspected CDG1A, revealed a typical CDG1 pattern. Fibroblast test confirmed PPM deficiency, molecular study revealed homozygosity for p.R141 H mutation (Dr. Jaak Jaeken) Trough this presentation we aim to contribute to a better knowledge of this inherited error of metabolism, tending to increase the suspicion index and improve the follow up of CDG patients and families.
822 - PMM2-CDG and Sensorineural Hearing Loss
Cigdem Seher Kasapkara1, Zeren Bariş2, Mustafa Kiliç1, Deniz Yüksel1, Lies Keldermans3, Gert Matthijs3, and Jaak Jaeken4
1Dr. Sami Ulus Children's Hospital, Ankara, Turkey
2Başkent University, Ankara, Turkey
3Department of Human Genetics, Ku Leuven, Leuven, Belgium
4Department of Development and Regeneration, Ku Leuven, Leuven, Belgium
A two-year-old boy was referred for evaluation of psychomotor disability, hypotonia, and sensorineural deafness since infancy. There was no hearing impairment in the family according to the parents. Physical examination showed a height of 80 cm (below 3 rd centile = 82 cm), weight of 8.2 kg (below 3 rd centile = 10.5 kg), and head circumference of 43 cm (below 3 rd centile = 47.3 cm). He showed facial dysmorphism (hypertelorism, small rounded nose, pronounced philtrum, thin upper lip, high palate, and micrognathia), a keel thorax, inverted nipples, abnormal fat distribution and mild hepatomegaly. Eyes were wide set with a shallow nasal bridge and synophrys. He had severe hypotoniaand hyporeflexia. He was not able to sit unsupported and was nonverbal. Blood investigation showed increased serum transaminases [AST: 1689 U/L, ALT: 1049 U/L(normal range: 0-40 U/L)] and gamma-GT: 29 U/L(normal:4-18 U/L). PT, aPTT, antithrombin, and factor XI were normal. Ultrasonographic examination showed minimally enlarged liver size with normal echogenicity. Echocardiography and ophthalmological evaluation were normal. Brain MRI showed cerebellar atrophy and widening of the posterior fossa and pericerebellar space. A type 1 pattern was found on serum transferrin isoelectrofocusing, and he was found to be homozygous for the known PMM2 variant c.385G>A (p.Val129Met).The present patient had thus PMM2-CDG (phosphomannomutase 2 deficiency), the most common N-glycosylation defect. Two CDGs have been significantly associated with deafness namely RFT1-CDG (10 out of 13 patients) and ALG11-CDG (4/9). As to PMM2-CDG, we found 15 reports with altogether 20 patients showing sensorineural hearing loss/hearing impairment. At least 700 patients have been reported with PMM2-CDG. Although, calculation results in a 3% prevalence of hearing impairment in this CDG. On the other hand, hearing impairment is not rare in the general population. According to the WHO, hearing impairment in the European general population has a prevalence between 3.2 and 13% depending on the population considered. From these data, it seems that hearing impairment in PMM2-CDG is not a symptom but a coincidental finding.
823 - Toward a PMM2-CDG Therapy: Optimization Process of Potential Pharmacological Chaperones
Alvaro Briso-Montiano1, Alejandra Gamez1, Sandra Brasil1, Lourdes R. Desviat1, Magdalena Ugarte1, Jose Manuel Garcia2, Celia Pérez-Cerdá1, and Belen Pérez1
1Centro de Diagnóstico de Enfermedades Moleculares. Universidad Autonoma de Madrid, Madrid, Spain
2Instituto de Investigaciones Químicas, Csic, Sevilla, Spain
The functional characterization of Phosphomannomutase 2 (PMM2) disease-causing mutations has suggested that PMM2-CDG could be a conformational disease and that therapies addressed to improve the protein folding would be able to ameliorate clinical symptoms. From a 10 000 compound library screening, 8 possible pharmacological chaperones (PCs) were selected. The compound 1-(3-chlorophenyl)-3-3-bis(pyridine-2-yl) urea (compound VIII) stood out, based on its pharmacochemical properties, showing no inhibitory effect on PMM2 enzymatic activity and enhancing the activity and stability of a number of destabilizing PMM2 mutations. These results provided the first proof-of-concept of a possible treatment for PMM2-CDG and identified a promising chemical structure as a starting lead for the development of new therapeutic agents against this severe orphan disease. The aim of this work was setting-up an optimization process by methodological sequential rounds from a battery of chemical analogs of compound VIII in order to improve the physicochemical properties and cytotoxicity.
824 - Maternal Uniparental Isodisomy Causing a New Case of B4GALT1-CDG (CDG IId)
Belen Pérez1, Celia Pérez-Cerdá1, Lorena Monge2, Yolanda Gonzalez Irazabal2, Ana Rodriguez Valle2, and María Concepción García-Jiménez2
1Centro de Diagnostico de Enfermedades Moleculares. Universidad Autonoma de Madrid. Ciberer, Madrid, Spain
2Hu Miguel Servet, Zaragoza, Spain
825 - Would Congenital Disorders of Glycosylation Incidence be Higher Than the Expected?
Aynur Kucukcongar Yavas1, Esra Gurkas1, Özlem Ünal1, Mehmet Gunduz1, and Jaak Jaaken2
1Child Health and Diseases Hematology Oncology Education and Training Hospital, Ankara, Turkey
2University of Leuven, Leuven, Belgium
Congenital disorders of glycosylation (CDGs) cause impaired synthesis of glycoconjugates and are genetically heterogeneous with pathogenic variants over one hundred genes that can cause it. ALG1 mutations cause rare autosomal recessive disorder, called ALG1-CDG. Main devastating features are neurodevelopmental retardation with multisystem involvement. But, it is difficult to diagnose when there are no stimulative findings. Here presented an ALG1-CDG case, who has unexplained seizures and neurodevelopmental delay.
826 - Intellectual Disability With Autistic Features as Atypical Presentation of ALG8-CDG due to Novel Gene Variants Detected by Targeted Resequencing
Lorenzo Ferri1, Beatrice Berti1, Francesco Mari1, Maria Alice Donati1, Elena Procopio1, Duccio Malesci1, Rita Barone2, Davide Mei1, Elena Parrini1, Renzo Guerrini1, and Amelia Morrone1
1Meyer Children's Research Hospital, Firenze, Italy
2University of Catania, Firenze, Italy
827 - ALG13 Deficiency Causes X-Linked Mental Retardation and Congenital Disorder of Glycosylation Type I
Andrea Zuehlsdorf1, Carina Belting2, Marianne Grueneberg1, Janine Reunert1, Stephan Rust1, and Thorsten Marquardt1
1Universitaetsklinik Muenster Klinik Für Kinder- Und Jugendmedizin, Muenster, Germany
2Klinik Hirslanden Notfallzentrum, Zuerich, Switzerland
828 - ATP6AP2 Deficiency Causes a Congenital Disorder of glycosylation type II and Impaired Autophagy
Andrea Zuehlsdorf, Janine Reunert, Julien H Park, Stephan Rust, Marianne Grueneberg, and Thorsten Marquardt
Universitaetsklinik Muenster Klinik Für Kinder- Und Jugendmedizin, Muenster, Germany
829 - Common Point of Congenital Disorders of Glycosylation Type Ia and Hereditary Fructose Intolerance
Ebru Canda, Havva Yazici, Esra Ben, Sema Kalkan Uçar, and Mahmut Çoker
Pediatric Metabolism and Nutrition, Ege University Faculty of Medicine, Izmir, Turkey
Congenital disorders of glycosylation (CDG) are caused by defective glycosylation of proteins and lipids. Patients with CDG show a very broad spectrum of clinical manifestations. Isolectrofocusing of serum transferrin (IEF) is a screening method of choice for N-glycosylation disorders. Three patients with CDG 1a and one hereditary fructose intolerance were presented with different clinical features showing type 1 pattern characteristics. A 5-year-old boy presented with hypertrophic cardiomyopathy, growth retardation and elevated transaminase levels. On his physical examination, dysmorphic face, pectus carinatus deformity, inverted nipples, axial hypotonia and distal spasticity, 2/6 systolic murmur, and pubic fat pads were detected. Cranial MR revealed bilateral cerebellar atrophy. On abdominal ultrasound hepatosteatosis was detected. PMM2 gene analysis revealed homozygous mutations. Two siblings at the age of 2 years and 4 years complaint about motor mental retardation. Axial hypotonia, distal spasticity, inverted nipples were detected. Cranial MR revealed cerebellar hypoplasia in one of the sibling and corpus callosum agenesia in the other. In the PMM2 gene analysis compound heterozygote mutations were detected. A 3.5-year-old female patient was evaluated for transaminases elevations, hypoalbuminemia, coagulopathy, metabolic acidosis. Physical examination revealed dysmorphic facial features, fat pads in the gluteal region and hepatosplenomegaly. Type 1 pattern was detected in IEF of serum transferrin. But forward genetic analysis revealed a homozygous mutation in the ALDOB gene and the patient was diagnosed as hereditary fructose intolerance. In the presence of unexplained neurological findings, cerebellar atrophy, abnormal liver function tests, coagulopathy, cardiomyopathy, growth retardation, skeletal involvement findings CDG should be kept in mind. IEF can be used as a screening method. It should not be forgotten that IEF may be false positivity in hereditary fructose intolerance.
830 - De Novo Variant Identified for WES in ALG13, First Report of CDG-1 s in a Colombian Patient
Diana Ramirez1, Juan Pablo Benavidez2, and Harry Pachajoa3
1Ciacer, Universidad Icesi, Cali, Colombia
2Fundación Valle Del Lili, Cali, Colombia
3Ciacer, Universidad Icesi and Fundación Valle Del Lili, Cali, Colombia
831 - A Development Delay and Dysmorphic Case With ALG13 Gene Pathogenic Mutation Identified by WES
Aida Lemes1, Gabriel González2, Paola Audicio3, Cristina Zabala4, and Cecilia Queijo5
1Laboratorio de Pesquisa Neonatal. Unidad de Diagnostico Y Tratamiento. Cenadecer-Bps, Montevideo, Uruguay
2Servicio de Neuropediaria. Hospital Pereira Rossell., Montevideo, Uruguay
3Laboratorio de Pesquisa Neonatal. Cenadecer-Bps, Montevideo, Uruguay
4Unidad de Diagnostico Y Tratamiento. Crenadecer-Bps, Montevideo, Uruguay
5Laboratorio de Pesquisa Neonatal. Crenadecer. Bps, Montevideo, Uruguay
Glycosylation is an important and complex co- and posttranslational modification system involving some 1%-2% of all human genes. Congenital disorders of glycosylation (CDG) is a group of genetic diseases in which the synthesis of glycans and their union with glycoconjugates, proteins, and lipids is defective. This process occurs in cytosol, endoplasmic reticulum and the Golgi apparatus. Although, eight biochemical pathways are involved, the best characterized are that involved in the N- and O-glycosylation of proteins. About 50 genetic defects have been described that affect N-glycosylation of proteins, either isolated or in combination with effects on O-glycosylation. Phosphomannomutase 2 (PMM2)-CDG of the N-glycosylation is the most common type of CDG. The ALG13 gene defect on N-glycosylation is infrequent and normally, catalyzes the second step of lipid-linked oligosaccharide (LLO) biosynthesis. This defect has X-linked inheritance. Most CDG with N-glycosylation defect are multi-organ diseases with neurological involvement. N-glycosylation disorders are associated with sialic acid deficiency and are detected by serum transferrin isofocusing (IEF). Is our aim, to present a case of ALG 13 gene pathogenic mutation detected by WES, with clinic consistent with CDG and with normal serum transferrin IEF profile.
X) Neurotransmitter and Creatine Related Disorders (832 to 840)
832 - Neurometabolic Disorders in a Cohort of 221 Children Below Two Years of Age With Epilepsy: A Single-Center Experience in Saudi Arabia
Sarar Mohamed1 and Ebtisam Elmeleagy2
1Prince Sultan Military Medical City, Riyadh, Saudi Arabia
2Saad Specialist Hospital, Alkhobar, Saudi Arabia
833 - Effect of Guanidinoacetate on Memory and Oxidative Status in Striatum
Eduardo Peil Marques, Tiago Marcon, Cassiana Siebert, Fernanda Ferreira, Carolina Gessinger Bertó, and Angela Wyse
Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
Guanidinoacetate Methyltransferase (GAMT) deficiency is an autosomal recessive inherited disorder of the metabolism of creatine that leads to depleted levels of creatine and excessive concentrations of guanidinoacetate. Patients affected develop neurological symptoms during childhood, such as muscular hypotonia, involuntary extrapiramidal movements, convulsions, slurred speech, and even autism. Although the pathophysiology of GAMT deficiency is unclear, neurological dysfunction is commonly found in this disease and it has been mainly attributed to reduction of creatine or/and increase of guanidinoacetate (GAA) levels. This study’s objective was to investigate the effects of an intrastriatal administration of GAA on non-aversive behavioral test and parameters of oxidative stress such as 2′7′dichlorofluorescein (DCF) oxidation and antioxidant enzyme activities. Sixty days Wistar rats received a single intrastriatal GAA administration or saline 48 hours after stereotactic surgery. Animals were subjected to behavioral or striatum biochemical tests 1 hour after the infusion. In the novel object recognition test, the time exploring the novel object increased in the control group (P ≤ .05), while the same did not happened in treated animals. GAA significantly decreased the activity of superoxide dismutase (SOD) (P ≤ .01) and catalase (CAT) (P≤ .01) as well as increased DCF oxidation (P ≤ .01). A pretreatment with creatine for seven days prior to the surgery was able to prevent all alterations, except CAT activity. In conclusion, it is possible to presume that these biochemical alterations caused by high levels of GAA may contribute to neurological alterations found in patients with GAMT deficiency. Furthermore, it is possible that creatine supplementation helps to prevent these features. Supported by CNPq.
834 - Creatine Synthesis Defects: Experience of 3 Indian Patients
Anil Jalan1, Monal Borugale1, Ketki Kudalkar1, Rishikesh Jalan1, Durga Shinde1, Rasika Tawde1, Neelam Yadav1, Gauri Gaikwad1, Manish Parakh2, Ankit Panday2, and Vivek Jain3
1Navi Mumbai Institute of Research in Mental and Neurological Hanidcap, Navi Mumbai, Maharashtra, India
2Department of Paediatrics, Dr S N Medical College, Jodhpur, Rajasthan, India
3Departtment of Paed Neurology, Sdmh Medical College, Jaipur, Rajasthan, India
835 - In Vitro Study of a New Pathogenic Variant of Human 6-Pyruvoyl-Tetrahydrobiopterin Synthase
Cynthia Fernandez-Lainez1, Sergio Enríquez-Flores1, Gabriel López-Velázquez1, David Marin-Urdapilleta1, Ariadna Gonzalez-Del Angel1, Miguel Angel Alcantara-Ortigoza1, Liliana Fernandez-Hernandez1, Itzhel Garcia-Torres1, Ignacio de La Mora-De La Mora1, Sara Guillén López1, Leticia Belmont-Martinez1, Lizbeth Lopez-Mejia1, Isabel Ibarra-Gonzalez2, and Marcela Vela-Amieva1
1Instituto Nacional de Pediatria, Mexico City, Mexico
2Instituto de Investigaciones Biomedicas, Unam, Mexico City, Mexico
836 - Diabetic Ketoacidosis in Vanishing White Matter
Fuad Al Mutairi
King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia
Vanishing white matter (VWM) disease (OMIM #603896) is an autosomal recessive chronic and progressive leukodystrophy and is one of the most prevalent inherited childhood leukoencephalopathies. The symptoms of the disease can begin shortly after birth or in adulthood. The phenotypic variation is very wide and the most common features include neurological deterioration, optic atrophy, seizures, coma, and death [3, 4, 5]. VWM disease is diagnosed on the basis of the clinical symptoms in combination with MRI results and molecular testing. Five Eukaryotic Initiation Factor “EIF” genes are known to be involved in VWM disease: EIF2B1, EIF2B2, EIF2B3, EIF2B4, and EIF2B. Hyperglycemia and diabetic ketoacidosis (DKA) have never been reported before in patients with VWM disease. We are reporting on a case with both VWM disease and DKA, and so to the best of our knowledge, this is the first case of a similar presentation. He was admitted at the age of 8 months through the emergency department with irritability and vomiting and was found to have a blood glucose level (25 mmol/L), HbA1c (11.4%), as well as ketosis (Ketones +3), metabolic acidosis (plasma bicarbonate 15 mEq/L), C-Peptide (22 pmol/L), Glutamate decarboxylase Abs (4 IU/mL), Islet Cells Abs (Negative; normal, Negative), and blood PH (7.1). The patient was readmitted again with intractable seizures and generalized tonic–clonic convulsions, and a CT scan of his brain showed diffuse confluent bilateral symmetrical low attenuation in white matter consistent with leukodystrophy, which was confirmed by an MRI of the brain revealing diffuse white matter disease. Five genes that associated with neonatal and infantile diabetic syndromes (KCNJ11, ABCC8, INS, GCK, and PDX1), and muscle biopsy for defects in mitochondrial respiratory chain complexes were all negative. Here was a history of abortion at 2 months of gestation and premature death of a baby boy at 6 months gestation. Further investigations including Whole Exome Sequencing (WES) revealed a homozygous likely pathogenic variant in EIF2B1 NM_001414: c.146T>G p.(Leu49Arg) in the proband; both parents were heterozygous. This is the first case of an association between VWM disease and DKA which yields additional observations regarding the role of EIF2B1 in glucose regulation and expands the phenotype of VWM disease. However, the relation between the eIF2B protein complex and glucose level is unclear and requires further research.
837 - CSF PLP Deficiency in Inborn Errors of Metabolism: Implications for Treatment
Jose Ignacio Rodriguez Ciancio1, Emma Footitt1, Simon Heales1, Simon Pope2, Philippa Mills3, Peter Clayton3, and Helen Aitkenhead1
1Great Ormond Street Hospital, London, United Kingdom
2National Hospital for Neurology and Neurodisability, London, United Kingdom
3Ucl Institute of Child Health, London, United Kingdom
838 - X-Linked Creatine Transporter (SLC6A8) Deficiency Syndrome: A Report on an Argentinian Family With a Variable Clinical Phenotype
Hector Rodrigo Mendez1, Lucia Espeche1, Maria Del Carmen Martinez Perea2, Marina Szlago3, Sandra Rozental1, and Carlos Ruggiero1
1Centro Nacional de Genetica Medica, Ciudad de Buenos Aires, Argentina
2Hospital Rivadavia, Ciudad de Buenos Aires, Argentina
3Hospital de Niños Ricardo Gutierrez, Ciudad de Buenos Aires, Argentina
Cerebral creatine transporter deficiency, attributable to the deficiency in the SLC6A8 gene, causes X-linked mental retardation, epilepsy, language delay, and autistic features. In contrast with creatine synthesis defects, the majority of patients with SLC6A8 deficiency do not respond to treatment. We describe an Argentinian family with this condition: the proband and his brother, with psychomotor delay and severe speech impairment. The family also includes their sister with psychomotor retardation, predominantly in language, and their mentally retarded mother. The proband brain MRI indicated hemispheric white matter abnormalities, while MR spectroscopy indicated markedly reduced creatine peak. The proband biochemical testing indicated increased urine creatine/creatinine ratio, with normal plasma creatine and guanidinoacetate. His 17-year-old brother and 18-year-old sister had similar biochemical and clinical abnormalities. To confirm the diagnosis in the proband and his brother, sister and mother the SLC6A8 analysis by Multiplex ligation-dependent probe amplification (MLPA) showed an aberrant pattern, as a possible deletion in exon 3 of SLC6A8. To confirm the results the cDNA sequence analysis of the SLC6A8 is in actual process in our Molecular Diagnostics Laboratory. This family illustrates the remarkable phenotypic variability in this condition. Investigation of creatine metabolism, brain MR spectroscopy are mandatory in patients with developmental delay of unknown etiology and molecular testing is useful to confirm the diagnosis.
839 - Tyrosine Hydroxylase Deficiency: A Report of Three Patients With a Severe Early Onset Form
Rim Ben Abdelaziz1, Meriem Khalfa2, Hela Hajji2, Hela Boudabous1, Amel Ben Chehida1, Ichraf Kraoua3, Mohamed Slim Abdelmoula1, Jean-François Benoist4, Ilhem Turki3, Hatem Azzouz1, and Neji Tebib5
1La Rabta Hospital, Université Tunis Elmanar, Faculté de Médecine de Tunis, Tunis, Tunisia
2La Rabta Hospital, Tunis, Tunisia
3Institut Mongi Ben Hamida de Neurologie, Tunis, Tunisia
4Service de Biochimie Hormonologie, Hôpital Robert Debré Paris, Paris, France
5La Rabta Hospital, Université Tunis Elmanar, Faculté de Médecine de Tunis, Tunisia, Tunisia
Tyrosine hydroxylase (TH) deficiency also called Dopa responsive dystonia is a rare autosomal recessive disorder resulting from cerebral catecholamine deficiency. Actually, Based on severity of symptoms and signs as well as responsiveness to levodopa therapy, there are three clinical phenotypes attributable to pathogenic variants in TH.
840 - Monoamine Neurotransmitter Disorders in a Chilean Cohort of Infants and Children
Monica Troncoso1, Paola Santander1, Diane Vergara1, Javiera Tello1, Valentina Naranjo1, Carla Rojas1, Alvaro Wicki1, Paulina Alid1, and Magdalena Gonzalez2
1Pediatric Neuropsychiatry Unit, San Borja Arriarán Hospital. Faculty of Medicine University of Chile, Santiago, Chile
2Mgonzalez4@Miuandes.Cl, Santiago, Chile
Y) Disorders of Vitamins, Cofactors, and Trace Elements (841 to 860)
841 - Novel Mutations of the ATP7B Gene in Czech Families With Wilson’s Disease
Dagmar Procházková1, Slavka Pouchla2, Milan Dastych3, Petra Konečná4, and Lenka Fajkusová5
1Medical Faculty of Masaryk University and University Hospital Brno, Dpt. of Pediatrics, Brno, Czech Republic
2University Hospital Brno, Centre of Molecular Biology Nad Gene Therapy, Brno, Czech Republic
3University Hospital Brno, Dpt. of Biochemistry, Brno, Czech Republic
4University Hospital Brno, Dpt. of Pediatrics, Brno, Czech Republic
5Medical Faculty of Masaryk University and University Hospital Brno, Centre of Mol Biol Gene Therap, Brno, Czech Republic
842 - Skin Lesions in Cobalamin C Disease are Associated With Poor Metabolic Control and are Reversible
Pankaj Prasun, Cristel Chapel-Crespo, and Suzanne Miller
Icahn School of Medicine at Mount Sinai, New York, NY, USA
An 8-year-old boy with Cobalamic C disease developed multiple skin ulcers. He was diagnosed with Cobalamic C disease by newborn screening and was treated with vitamin B12 injections and cystadane from beginning. However, family was poorly compliant with treatment. At time of this presentation, his homocysteine was 181.2 micromole/liter (normal <11). In addition, plasma methionine was very low and plasma methylmalonic acid was high. Home care nursing and school health services were involved to ensure compliance with treatment. Vitamin B12 injections were given by nurse and cystadane administration was supervised. Within a week, lesions started improving and healed by 6 weeks of supervised therapy. Metabolic parameters (homocysteine, methionine and methylmalonic acid) showed improving trend along with improvement in the lesions. Skin lesions in Cobalamin C disease has been rarely described. It was thought to be due to nutritional deficiencies associated with dietary restrictions or due to untreated metabolic condition. Biopsy of a new onset lesion of this patient showed acanthosis, spongiosis and perivascular lymphocytic and eosinophilic infiltrates. Our observation suggests that skin lesion in Cobalamin C disease is associated with poor metabolic control rather than nutritional deficiencies and probably a manifestation of microangiopathy characteristic of this disorder. Appearance of these lesions in a known patient suggests either poor compliance or inadequate dose and should be addressed promptly. Normal range in parenthesis
* normal range
843 - Challenges in Diagnosis of Wilson Disease in a Limited Resource Country
Winra Pratita, Nice Rachmawati, and Damayanti Rusli Sjarif
University of Indonesia, Jakarta, Indonesia
844 - Biotidinase Deficiency: Novel Mutations in Algerian Patients
Hamlaoui Mohamed1, Mekki Azzedine2, Tiar Afaf3, Abdelhak Sonia3, and Lebied Amar2
1Chu H-Dey Algiers Algeria, Algiers, Algeria
2Pediatrics Chu Hussein Dey, Algiers, Algeria
3Genetique Institut Pasteur, Tunis, Tunisia
845 - Mutations in PROSC Disrupt Cellular Pyridoxal Phosphate Homeostasis and Cause Vitamin B6-Dependent Epilepsy in Man
Philippa Mills1, Karin Tuschl2, Niklas Darin3, Emma Reid1, Laurence Prunetti4, Lena Samuelsson5, Ralf Husain6, Matthew Wilson1, Emma Footitt7, Karine Lascelles8, Mike Champion8, Evangeline Wassmer9, Pierangelo Veggiotti10, Valérie de Crécy-Lagard4, Steve Wilson2, and Peter Clayton1
1UCL Gos Institute of Child Health, London, United Kingdom
2Department of Cell and Developmental Biology, University College London, London, United Kingdom
3Department of Pediatrics, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
4Department of Microbiology & Cell Science, Institute for Food and Agricultural Sciences and Genetics, Gainesville, FL, USA
5Department of Clinical Genetics, Sahlgrenska University Hospital, Gothenburg, Sweden
6Centre for Inborn Metabolic Disorders, Department of Neuropediatrics, Jena University Hospital, Jena, Germany
7Department of Metabolic Medicine, Great Ormond Street Hospital Nhs Foundation Trust, London, United Kingdom
8Evelina Children’s Hospital, St Thomas Hospital, London, United Kingdom
9Birmingham Children’s Hospital, London, United Kingdom
10Department of Child Neurology and Psychiatry C. Mondino National Neurological Institute, Pavia, Italy
846 - Pyridox(am)ine 5’-Phosphate Oxidase Activity in Patients With Vitamin B6 Responsive Epilepsy: Findings and the Effect of the Common p.R116Q Variant Upon Enzymatic Activity
Matthew Wilson1, Emma Footitt2, Apostolos Papandreou1, Mari-Liis Uudelepp2, Ronit Pressler2, Danielle Stevenson2, Camila Gabriel2, Mel Mcsweeney2, Matthew Baggot2, Derek Burke2, Tommy Stödberg3, Kate Riney4, Manuel Schiff5, Simon Heales2, Kevin Mills1, Paul Gissen1, Peter Clayton1, and Philippa Mills1
1UCL Institute of Child Health, London, United Kingdom
2Great Ormond Street Hospital for Children Nhs Foundation Trust, London, United Kingdom
3Karolinska University Hospital, Stockholm, Sweden
4The Lady Cilento Children's Hospital, Brisbane, Australia
5Robert Debré University Hospital, Paris, France
847 - Good Initial Response to Medical Treatment in a Patient With Late-Onset Methylmalonic Aciduria and Homocystinuria due to Cobalamin D Disorder
Javier de Las Heras1, Luis Aldámiz-Echevarria1, Elsa Ramos2, Jesus Cortes3, Juan Carlos Arango3, Alberto Cabrera4, Amagoia Elosegui1, and Fernando Andrade1
1Hospital Universitario Cruces, Bilbao, Spain
2Hospital Santiago, Vitoria, Spain
3Biocruces Health Research Institute, Bilbao, Spain
4Osatek, Galdakano, Spain
The Cobalamin D (CblD) disorder is a rare autosomal recessive disease of cobalamin metabolism caused by mutations in the MMADHC gene that can result in isolated Homocystinuria, isolated Methylmalonic aciduria, or combined Methylmalonic aciduria and Homocystinuria (MMA/HC). Only a few patients with CblD defect have been described, and those with the MMA/HC phenotype typically present with developmental delay, seizures, hypotonia, lethargy and megaloblastic anemia. We present the case report of a 12-year-old male, who started at 10 years and 5 months of age with progressive encephalopathy with regression, deterioration in school performance, behavioral and personality changes, and episodes of acute mental confusion and lethargy. Eleven months after the first symptoms he was referred to our clinic. On our first evaluation, he presented evident disorientation, inattention and serious mental slowness. CUMANES (School-Age Neuropsychological Maturity Test) and WISC-IV (Weschler Intelligence Scale) test were performed, indicating very poor performance in visual and verbal memory. Laboratory test showed increased plasma homocysteine (HC) and methylmalonic acid (MMA) levels (143.9 µmol/L and 67.8 µmol/L), while methionine levels were within the normal range (18 µmol/L). Genetic testing showed a novel mutation in heterozygosis in the MMADHC gene. Treatment with intramuscular OH-Cbl, betaine and folinic acid was prompt initiated, with a rapid decrease in HC and MMA levels, and an increase in methionine levels. Soon after the treatment initiation, the patient started feeling better, presenting no more episodes of behavioral and personality changes or acute mental confusion. In 4 months, there was a rapid weight increase, from 31.8 kg (3rd-10th percentile) to 41 kg (25th-50th percentile). The neuropsychological examination 4 months after treatment initiation showed improvement in visuospatial skills, from apraxia to normal score, and cognitive speed processing (from score 57 to 67), without improvement in working memory or semantic verbal fluency.
848 - Early Diagnosis of Riboflavin Transporter Deficiency and Therapeutic Management—A Case Report
Gustavo Marquezani Spolador1, Sofia Ortiz Saldaña1, Diana Salazar Bermeo1, Cristina Núñez Vaca1, Santiago Estrella Benavides1, Débora Romeo Bertola1, Guilherme Lopes Yamamoto1, Rachel Sayuri Honjo1, Erasmo Casella Barbante2, and Chong Ae Kim1
1Genetics Unit of Instituto da Criança do Hospital das Clínicas da Universidade de São Paulo, São Paulo, SP, Brazil
2Neuropediatrics Unit of Instituto da Criança do Hospital das Clínicas da Universidade de São Paulo, São Paulo, SP, Brazil
Brown-Vialetto-Van Laere Syndrome was described in 1894 as a progressive neuropathy in association with childhood amyotrophic lateral sclerosis. In 2010 mutations in the SLC52A3 were found as the etiology of this affection. This gene encodes a riboflavin transporter, which is expressed in the small intestine and the brain. The clinical findings comprise weakness, hearing loss, sensory ataxia, feeding, and respiratory difficulties. The cognition is normal, and the progressive course of disease can be modified with early therapeutic management through the administration of riboflavin.
849 - High Parenteral Hydroxocobalamin Dose Strategy in 5 Patients With Different Types of Intracellular Cobalamin Deficiency: Clinical and Biochemical Evolution
Emmanuel Scalais1, Elise Osterheld1, Christine Geron2, Charlotte Pierron2, Dina Amrom2, Christiane Weitzel2, Ronit Chafai2, Vincent Schlesser2, Johan Van Hove3, and Linda de Meirleir4
1Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg;
2Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
3University of Colorado, School of Medicine, Aurora, CO, USA
4Universitair Ziekenhuis, Brussel, Belgium
850 - A Novel homozygous Variant c.437TG in COQ4, Related to Ubiquinone Biosynthesis, Presenting With Severe Infantile Spastic Quadriplegia, Dystonia, and Seizures in Two Siblings
Mari-Liis Uudelepp1, Philippa Mills2, Peter Clayton2, Hywel Williams2, Polona Le Quesne Stabej2, Louise Ocaka2, Emma Reid2, and Paul Gissen2
1Metabolic Medicine Department, Great Ormond Street Hospital for Children Nhs Foundation Trust, London, United Kingdom
2Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
851 - Mutations in SLC39A14 Lead to Manganese Neurotoxicity and Childhood Onset Dystonia-Parkinsonism That may be Amenable to Chelation Therapy With Na2CaEDTA
Philippa Mills1, Esther Meyer2, Leonardo Valdivia3, Alaa Abdul-Sada4, Wui K. Chong5, Thomas Jacques5, Laila Selim6, Fatma Al Jasmi7, Jin-Hong Shin8, Guillem Pintos-Morell9, Russell Dale10, Maya Thomas11, Jason Rihel3, Olaf Bodamer12, Caroline Enns13, Susan Hayflick13, Peter Clayton1, Manju Kurian1, Steve Wilson3, and Karin Tuschl1
1Ucl Gos Institute of Child Health, London, United Kingdom
2North Bristol Nhs Trust, Bristol, United Kingdom
3University College London, London, United Kingdom
4Sussex University, Brighton, United Kingdom
5Great Ormond Street Hospital, London, United Kingdom
6Cairo University, Cairo, Arab Republic of Egypt
7Tawam Hospital, Al Ain, United Arab Emirates
8Pusan National University Yangsan Hospital, Yangsan, South Korea
9Hospital Germans Trias I Pujol, Badalona, Spain
10The Children's Hospital at Westmead, Sydney, Australia
11Christian Medical College, Vellore, India
12Boston Children’s Hospital, Boston, USA
13Oregon Health & Science University, Portland, USA
852 - Inherited Disorders of Metal Metabolism: A Rare Case of Occipital Horn Syndrome
Pedro Louro1, Lina Ramos1, Renata Oliveira2, Margarida Henriques3, Ester Pereira3, Stephen Kaler4, Janet Pereira5, Luísa Diogo6, and Paula Garcia6
1Medical Genetics Unit, Pediatric Hospital, Chuc, Coimbra, Portugal
2Medical Genetics Unit, Chsj, Porto, Portugal
3Department of Pediatrics, Chl, Leiria, Portugal
4Section on Translational Neuroscience, Molecular Medicine Branch, NICHD, NIH, Bethesda, MD, USA
5Molecular Hematology Unit, Pediatric Hospital, Chuc, Coimbra, Portugal
6Metabolic Diseases Unit, Pediatric Hospital, Chuc, Coimbra, Portugal
853 - Menkes Disease and Cooper Sulfate Treatment
Maria Del Carmen Martinez Perea
Hospital B. Rivadavia. Department of Neurology (Neuro Pediatric Area), Buenos Aires, Argentina
854 - Cobalamin C Disease Presenting as Hemolytic Uremic Syndrome in a Chinese Newborn
A Lin1, Chong SC1, D Tang1, S Ho1, Lk Law2, Yuen YP2, Hui J1
1Department of Paediatrics, Prince of Wales Hospital, Hong Kong, Hong Kong
2Department of Chemical Pathology, Prince of Wales Hospital, the Chinese University of Hong Kong
855 - Brown-Vialetto-Van Laere syndrome—Life-Threatening but Treatable Vitamin B2-Transporter Defect
Janine Reunert, Andrea Zuehlsdorf, Stephan Rust, and Thorsten Marquardt
Zentrum Für Kinder- Und Jugendmedizin, Universitätsklinikum Muenster, Muenster, Germany
856 - Prenatal Treatment of Pyridox(am)ine 5’-Phosphate Oxidase Deficiency With Normal Development at 18 Months of Age
Samia Pichard1, Juliette Bouchereau1, Peter Clayton2, Jean-François Benoist1, and Manuel Schiff1
1Reference Centre for Inborn Errors of Metabolism, Robert Debré University Hospital, Paris, France
2Great Ormond Street Hospital, London, United Kingdom
857 - Genotype–Phenotype Correlation in Biotinidase Deficiency Patients in Turkey
Mustafa Kiliç1 and Koksal Ozgul2
1Sami Ulus Children Hosp., Metabolism Unit, Ankara, Turkey
2Hacettepe University, Children Hosp., Metabolism Unit, Ankara, Turkey
858 - Screening for Biotinidase deficiency, A Collaborative Pilot Study Between Guatemala and Switzerland
Gabriel de Jesus Silva1, Maria Lucia Silva Polanco1, Maria Antonieta Sandoval1, and Ralph Fingerhut2
1Obras Sociales del Santo Hermano Pedro, Antigua Guatemala, Guatemala
2Newborn Screening Laboratory, Children’s Research Centre, University Children’s Hospital, Zurich, Sw, Zurich, Switzerland
Biotinidase is an important part in human metabolism. Biotinidase deficiency is an autosomal recessive disease affecting the biotin metabolism, via alteration of the enzyme biotinidase. Biotin, acts as the prosthetic group of four carboxylases, essentials in metabolic processes like gluconeogenesis, fatty acid synthesis and amino acid catabolism. Important neurological problems such as mental retardation and skin conditions can be caused by biotinidase deficiency. Scientific efforts between Guatemala and Switzerland National Newborn Screening Program are being done to implement the Basic panel for Neonatal Screening Program in Guatemala.
859 - Effect of BTD Gene Variants on In Vitro Biotinidase Activity
Taciane Borsatto1, Fernanda Sperb-Ludwig1, Henk Blom2, and Ida V D Schwartz3
1Post Graduate Program in Genetics and Molecular Biology, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
2Laboratory of Clinical Biochemistry and Metabolism, University Medical Centre Freiburg, Freiburg, Germany
3Medical Genetics Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
860 - Menkes Disease With Novel Mutation ATP7A Gene: c.3913G>A
Emilly de Jesus Garcia Ataíde1, Maria Juliana Rodovalho Doriqui2, and Patrícia da Silva Sousa3
1Universidade Federal do Maranhão, São Luís, MA, Brazil
2Hospital e Maternidade Marly Sarney, Hospital Infantil Dr. Juvêncio Matos, São Luís, MA, Brazil
3Hospital Infantil Dr. Juvêncio Matos, São Luís, MA, Brazil
Z) Miscellaneous (861 to 919)
861 - Electron Microscopy Still Has a role in Diagnosis of Inborn Errors of Metabolism: Retrospective Review of Autopsies at a Teaching Hospital
Mana Taweevisit1 and Paul Thorner2
1Department of Pathology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
2Department of Pathology and Laboratory Medicine, Hospital For Sick Children and University of Toronto, Toronto, Canada
862 - Coexistence of a Rare Disease With Novel Mutation and a Polymorphism That Cause of Speech Delay
Isil Ozer
19 Mayis University, Samsun, Turkey
863 - Potential Therapeutic Effect of Pyridoxal Phosphate on Collagen Type VI-Related Myopathies
Isil Ozer
19 Mayis University, Samsun, Turkey
864 - Toe Walking Caused by Inborn Error of Metabolic Diseases Following a Specific Case
Isil Ozer
19 Mayis University, Samsun, Turkey
865 - The Relationship Between Marfanoid Habitus and Methylentetrahydrofolate Reductase C677 T or A1298C Polymorphism
Isil Ozer1, Ozcihan Oguz2, and Bulent Uyanik3
119 Mayis University, Samsun, Turkey
2Medeniyet University, Istanbul, Turkey
3Bagcilar Public Hospital, Istanbul, Turkey
866 - Epidemiological Study of Inborn Errors of Intermediary Metabolism in a Single Specialized Reference Center in Mexico
Isabel Ibarra-Gonzalez1, Marcela Vela-Amieva2, Leticia Belmont-Martinez2, Cynthia Fernandez-Lainez2, Sara Guillén López2, and Lizbeth Lopez-Mejia2
1Unidad de GenéTica de La NutricióN, Instituto de Investigaciones BioméDicas, Unam, Mexico City, Mexico
2Laboratorio de Errores Innatos Del Metabolismo Y Tamiz, Inp, Ss, Mexico City, Mexico
867 - A Novel MC4 R Gene Mutation Associated With Early Onset Childhood Obesity—A Case Report
Petra Konecna1, Jana Stastna1, Lenka Kopecna1, Josef Vcelak2, and Dagmar Procházková1
1Department of Pediatrics, University Hospital Brno, Brno, Czech Republic
2Department of Molecular Endocrinology, Institute of Endocrinology, Prague, Czech Republic
The melanocortin-4-receptor gene (MC4 R) is a key regulator of energy homeostasis, food intake and body weight. MC4 R gene mutations are the most common cause of monogenic obesity. Monogenic obesity is described as rare and severe early-onset obesity with abnormal feeding behavior and endocrine disorders. MC4R-linked obesity is characterized by the variable severity of obesity and almost no notable additional phenotypes. Mutations in the MC4 R gene are involved in 2-3% of obese children and adults; the majority of these are heterozygous. Authors describe a case report of a two-year-old boy with early onset severe obesity, hyperfagia, body mass index (BMI) 25,3 kg/m2 (> 97th percentile), BMI SD score + 5,34 and increased linear growth. There was also a morbid obesity phenotype in the patient’s mother. Direct sequencing of the MC4 R gene was performed. A novel mutation -22 A/T in 5'UTR region was identified in the patient. We assume that this as-yet-undescribed mutation is linked to severe obese phenotype and might be a cause of monogenic obesity.
868 - Analysis of the NKX2.5 Gene in Mexican Patients With Primary Congenital Hypothyroidism due to Thyroid Dysgenesis
Ariadna Gonzalez-Del Angel, Miguel Angel Alcantara-Ortigoza, Irais Sanchez-Verdiguel, Victor Martinez-Cruz, and Carmen Sanchez
Instituto Nacional de Pediatria, Ciudad de Mexico, Mexico
Mexico has a high incidence of primary congenital hypothyroidism (CH) due to thyroid dysgenesis (TD) as 1:1000 live born is affected, although the environmental and/or genetic etiology factors are still unknown.
869 - Inhibitor-Induced In Situ Chaperone Therapy: A Novel Drug Targeting Strategy for Treating Metabolic Disorders
Al-Walid Mohsen, Anuradha Karunanidhi, Bianca Seminotti, Guilhian Leipnitz, Catherine Kochersperger, Lina Ghaloul-Gonzalez, Shrabani Basu, and Jerry Vockley
University of Pittsburgh, Pittsburgh, PA, USA
870 - Clinical Features and Long-Term Developmental Trends Of Pediatric Nonspecific Mitochondrial Disease
Soyong Eom1 and Young-Mock Lee2
1Yonsei University College of Medicine, Seoul, South Korea
2Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
Recent papers indicate that mitochondrial dysfunction can cause a higher proportion of uncategorized nonspecific encephalopathy as well as named disorders. This study aimed to evaluate the clinical features and long-term developmental trends in pediatric patients with nonspecific mitochondrial disease (MD). Data of 189 pediatric patients with nonspecific MD (85 males, 45%) were obtained from hospital records and the results of developmental evaluations using the developmental quotient (DQ). Additionally, disease-related clinical variables were reviewed. The age at onset of symptoms was 1.2 ± 1.6 years (0-9.1 years) and the nature of the initial symptoms varied, with developmental delay (83 patients, 44%) and seizures (74 patients, 39%) being the most frequent. The time from the first clinical presentation until the confirmative diagnosis of MD was 2.8 ± 2.7 years (0.03-16.9 years), regardless of the initial symptoms. In terms of severity of the clinical manifestations, all patients had involvement of the central nervous system, 48% (91) of patients had elevated serum lactic acid level, followed by seventy of 91 (37%) had mildly elevated levels, and 21 of 91 (12%) moderately and severely elevated levels of serum lactic acid. MRI studies of 56% patients (104 of 188) were abnormal and showed a variety of findings including atrophy or abnormal signals in different areas of the brain. Long-term follow-up over the course of 7.70 years showed declining trends over all studied periods. In patients diagnosed via syndromic diagnosis, non-significant differences in Development quotient (DQ) were observed between patients with nonspecific MD and those with Leigh syndrome. Age at the first symptom onset showed positive correlation with the level of developmental function at the post-diagnostic visit. Lead time to diagnosis was negatively associated with DQ at all-time points, but not reach statistical significance. Follow-up revealed consistent patterns of significant developmental deterioration of DQs during lead time, whereas no significant differences after diagnosis were observed. DQs might be a candidate as a predictor or a measure in pediatric MD by giving the functional level of patients, which is a very meaningful value in pediatrics. This research was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT and Future Planning (2016R1A2B4011052).
871 - Clinical Spectrum and Outcome of AIP Patients Without Heme-Arginate
Anil Jalan, Ketki Kudalkar, Rishikesh Jalan, Durga Shinde, Monal Borugale, Rasika Tawde, Neelam Yadav, Gauri Gaikwad
Navi Mumbai Institute of Research in Mental and Neurological Hanidcap, Navi Mumbai, India
872 - Founder Effect and Genotype/Phenotype Correlation in Colombian Patients With Hypophosphatasia
Juan Prieto1, Carlos Silvera2, Ana Maria Zarante Bahamón3, and Victor Vargas4
1Universidad Javeriana, Bogota, Colombia
2Universidad Del Norte, Barranquilla, Colombia
3Instituto Roosevelt, Bogota, Colombia
4Hospital Infantil San Jose, Bogota, Colombia
Hypophosphatasia is a rare inherited disorder of bone and mineral metabolism, caused by a deficiency of tissue-nonspecific alkaline phosphatase (TNSALP) secondary a mutations in the ALPL gene. Until now more than 330 mutations of ALPL gene have been identified. The strong allelic heterogeneity results in clinical heterogeneity, ranging from stillbirth with a poorly mineralized skeleton to pathologic skeletal fractures which develop in late adulthood only. We found that mutation c.892G>A (p.E298 K) is the most frequent in Colombian patients, previously reported in a Russian patient. We investigated whether it had a unique origin or rather multiple origins due to recurrence of de novo mutations. Our results show that all the p.E298 K mutations are carried by a common ancestral haplotype. We conclude a founder effect in Colombia and provide new evidence of the clinical variability in HPP patients.
873 - Analysis of the Mutation Spectrum of the FBN1 Gene in Russian Patients With Marfan Syndrome
Alla Semyachkina1, Tagui Adyan2, Olga Mironovich2, Ekaterina Nikolaeva1, and Alexander Polyakov2
1Research and Clinical Institute of Pediatrics Named After Yuri Veltischev of the Pirogov University, Moscow, Russia
2Research Centre for Medical Genetics of the Russian Academy of Sciences, Moscow, Russia
874 - Development of a Platform (Database Management System) for Information Management of the Expanded Newborn Screening Program in Nuevo León, Mexico
María Del Rosario Torres Sepúlveda1, Laura Elia Martínez Garza1, Nestor Ibarra Palomares1, Sara Elia Salazar Alvarez1, Jesús Zacarías Villarreal Pérez2, and Saul Gausin3
1Medicine School, Universidad Autónoma de Nuevo León, Monterrey Nuevo León, Mexico
2Departamento de Endocrinología, Hospital Universitario, Monterrey Nuevo León, Mexico
3Medicine School, Universidad Autónoma de Nuevo León, Monterrey, Nl, Mexico
875 - The Hematologic Manifestations of Inborn Errors of Metabolism: They are More Than Expected
Leyla Tümer1, Ertan Sal2, Ilyas Okur1, Ülker Koçak2, Zühre Kaya2, Fatih Süheyl Ezgü1, Alev Hasanoğlu1, and İdil Yenicesu2
1Gazi University School of Medicine Department of Pediatric Metabolic Disorders, Ankara, Turkey
2Gazi University School of Medicine Department Pediatric Hematology, Ankara, Turkey
Hematological problems are some of the most frequently observed findings of inherited metabolic diseases. These may be seen together with other systemic findings or sometimes as the first and only diagnostic finding of disease. Early determination of hematological findings has a positive effect on the prognosis of metabolic diseases. The aim of this study is to evaluate the incidence of hematological findings in inherited metabolic diseases since there are a few studies about the true incidence in literature. Three hundred eighteen patients who were being followed-up within the previous 6 months at Gazi University Department of Pediatric Nutrition and Metabolism, Turkey, were included in the study. Since patients were in different age groups, hematological findings were compared with normal values for each patient’s age group. The hematological findings were classified under seven main groups; anemia of chronic disease, iron deficiency anemia, vitamin B12 deficiency anemia, hemophagocytosis, leukocytosis and thrombocytosis[ük1]. Metabolic diseases were classified according to the textbook of Inborn Metabolic Diseases: Diagnosis and Treatment. Nine hundred twenty-two hematological examinations of the 318 patients were included to the study, and 283 hematological findings were determined, 127 anemia of chronic disease, 80 iron deficiency anemia, 56 cytopenia and four vitamin B12 deficiency anemia. Leukocytosis (n = 1), thrombocytosis (n = 5), and hemophagocytosis (n = 9) were also observed[ük2] . It was determined that although anemia of chronic disease and nutritional anemia are the most common hematological findings, these may be diagnosed late, while neutropenia, thrombocytopenia, pancytopenia and hemostasis disorders may be diagnosed earlier. Metabolic diseases must be considered in the evaluation of cytopenias, particularly in cases with an atypical cause that are resistant to treatment and have additional accompanying findings. Our study is the most comprehensive one in the literature, and we think it would positively contribute to the monitoring and prognosis of congenital metabolic diseases.
876 - Results From 15 Years of a Pioneer Free Service for Aid With Inborn Errors of Metabolism in Brazil
Claudio Magalhaes Dacier Lobato1, Luísa Di Santo D’Andréa2, Amanda Teixeira da Rosa1, Ana Paula Gravina Azevedo1, Alessandra Rohenkol de Souza Cardoso3, Karyn Regina Jordão Koladicz1, Lília Farret Refosco4, Roberto Giugliani4, and Carolina Souza4
1Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
2Escola de Saúde Pública do Rio Grande do Sul, Porto Alegre, RS, Brazil
3Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brazil
4Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
The Inborn Errors of Metabolism Information Service (SIEM, in Portuguese) is a free service that provides assistance in diagnosing, managing and supplying general information on Inborn Errors of Metabolism (IEM). Once contacted by a health professional, a standard form is completed with relevant clinical information which is registered in a database and analyzed by a specialist who will suggest diagnostic hypothesis, further laboratory and/or imaging markers, and, if necessary, emergency management. This cross-sectional study aims to analyze the results obtained by the SIEM from October 2001 until April 2017. The data was collected from the Service’s data bank. During this period, 3277 cases were registered. Most cases (89.4%) were registered by professionals that sought diagnostic and management assistance followed by 199 registrations (6.1%) seeking general information on IEM. 134 cases (4.1%) were registered for support for patients that had already been diagnosed with an IEM. The main medical specialties that contacted the SIEM are Pediatricians and/or Neonatologists (35.8%), Medical Geneticists (21.1%) and Neurologists and/or Neuropediatricians (20.1%); non-medical health professionals are responsible for 288 (8.9%) contacts. The purpose of the contacts was chiefly in regard to patients with symptoms that suggested an IEM (86.5%); the most frequent symptoms registered include Neuropsychomotor Development Delay (43.3%), Seizure (38.7%), Hypotonia (38.5%), Hepatomegaly (21.1%) and Vomit (20.3%). The onset of symptoms was mostly up to 1 year of age (68.4%). 2658 cases (81.1%), out of which, 329 (12.4%) were confirmed as an IEM distributed as such: 136 (41.3%) amino acid and peptide metabolism deficiency; 60 (18.3%) lysosomal metabolism deficiency; 39 (11.6%) energetic metabolism deficiency; 34 (10.4%) carbohydrate metabolism deficiency; 19 (5.9%) fatty acids and ketone bodies metabolism deficiency; 16 (4.9%) peroxisomal metabolism deficiency; 25 (7.6%) from other IEM. With such heterogeneous pathologies, the IEM occur fairly frequently as a group of metabolic conditions yet are rare when considered individually. Diagnosis is challenging due to non-specific symptoms with early onsets; however, it needs to be established with proper timing for an adequate and accurate management of the patient’s clinical status. The SIEM is an important tool for the endeavor of propagating information and proper orientation on inherited metabolic diseases.
877 - Increased Susceptibility for Mood Disorders and Altered Stress Adaptation in Male Mice With Suboptimal Mitochondrial Function
Tim Emmerzaal1, Elisabeth Vasileiou1, Bram Geenen1, Kyle Scott2, Brett Graham3, Craigen William3, Eva Morava2, Richard Rodenburg1, and Tamas Kozicz1
1Radboudumc, Nijmegen, the Netherlands
2Tulane University, New Orleans, LA, USA
3Baylor College of Medicine, Houston, TX, USA
An increasing body of evidence points toward the involvement of suboptimal mitochondrial function (SMF) in depression and other mood disorders. Several clinical and preclinical studies show that depression is associated with altered mitochondrial structure and function. Furthermore, stress, a major risk factor for depression, directly influences mitochondrial function. There is a surprising high association between mitochondrial disease and depression as well, which is estimated to be around 50%. This is significantly higher than the expected 16% depression prevalence in the general population. These findings suggest that SMF is causal in depression, however, this notion has not been substantiated yet. In this study, we tested the hypothesis that SMF influenced the animals’ stress response and impacted various biological domains linked to the pathobiology of depression. To test this hypothesis, a new genetically engineered mouse model was used. These animals have a deficiency of the NDUFS4 protein (Ndufs4def mice), a structural protein of complex I (CI), an essential component of the electron transport chain and oxidative phosphorylation. This deficiency leads to a 25% reduction of CI activity in the brain compared to WT mice. Despite this reduction, Ndufs4def mice exhibited no differences in body weight and temperature, physical activity (distanced travelled and velocity in the open filed), and motor coordination (Rotarod-test) compared to their WT littermates. After exposure to a chronic variable stress protocol, a well-validated animal model for depression, Ndufs4def mice showed increased anxiety like behavior (open field) as well as a disturbed day-night rhythm compared to WT animals, a symptom that can also be seen in individuals with depression. To provide mechanistic insights, we assessed the activation of brain nodes implicated in the pathobiology of depression. The expression of the protein FOS, a surrogate marker of neuronal activation, revealed distinct activation of several brain regions of WT and Ndufs4def mice. These results indicate a difference in functional coupling within and an altered balance between major brain networks, a well-established phenomenon in individuals with depression. In conclusion, here we report on distinct chronic stress-evoked responses in various biological domains in Ndusf4def and WT mice, supporting our hypothesis that suboptimal mitochondrial function mediates the impact of stress on mental health.
878 - Managing the Crisis: Rethinking the Provision of Specialized Metabolic Services for Underserved Populations
Georgianne Arnold and Mark Korson
Genetic Metabolic Center For Education, Boston, MA, USA
879 - Acylcarnitines in Cerebrospinal Fluid
Natalia Cesari and Niels Suldrup
Iaca Laboratorios, Bahía Blanca, Argentina
880 - Cleidocranial Dysplasia and Hypophosphatasia in a Child With RUNX2 Mutation
Victoria Voinova1, Alexander Mazur2, Vlasta Bobrynina3, and Egor Prokhortchouk2
1Research and Clinical Institute of Pediatrics Named after Yuri Veltischev at The Pirogov Russian Nat, Moscow, Russia
2Federal Research Centre of Biotechnology, Russian Academy of Sciences, Moscow, Russia
3Zao Genoanalytica, Moscow, Russia
Cleidocranial dysplasia (CCD; OMIM 119600) is a rare skeletal dysplasia arises from mutations causing haploinsufficiency of RUNX2 gene, coding an osteoblast transcription factor specific for bone and cartilage tissue. Hypophosphatasia (HPP; OMIM241500) is a rare disease associated with mutations of ALPL gene, resulting in deficiency of the tissue-nonspecific alkaline phosphatase (TNALP) activity and thereby impaired bone mineralization. A subset of patients with CCD have radiographic and biochemical features that overlap with HPP [Unger et al., 2002; El-Gharbawy et al., 2009]. It has been shown that ALPL expression is activated by RUNX2 (according to SIGNOR database). Runx2 deficient mice (+/−) have features of CCD with reduced alkaline phosphatase activity. We have observed a girl with signs of both diseases (HPP and CCD). She was born at 36 weeks by Caesarean section, weight 2190 g and length 47 cm[KK1], with APGAR scores 5/5. From the first day, she presented with respiratory failure (needed in respiratory support), hypotonia, hyporeflexia, soft bones of the skull, divergence of sagittal suture, and chest hypoplasia. Biochemical signs of HPP has been revealed: low levels of TNALP (64-107 units/L) and parathyroid hormone (0.3-7.6 pg/mL), moderately increased calcium and phosphorus in serum. Cranial deformation was developed and ultrasound signs of nephrocalcinosis were identified. At the age of 13 months she had low weight and height (8100 g, 72 cm), severely delayed motor development, narrow deformed thorax with deployed lower ribs. The clavicles were underdeveloped, formed only in the central parts, thinned. Most of symptoms corresponded to HPP, so the ALPL gene analysis was performed by the direct sequencing of the exons and the nearby regions. No pathogenic mutations were found, and the synonymous change c.330C>T (p.Ser110=) was revealed. Whole[KK2] exome sequencing was performed for the patient. There was found missense amino acid change Arg258Trp (Chr6:45,399,744, C→T, GRCh37/hg19) in the exon 4 of gene RUNX2. According to PolyPhen algorithm this amino acid change is probably pathogenic. We have assumed that RUNX2 mutation may lead to a decreased ALPL expression since its transcription is controlled by RUNX2. So clinical and biochemical signs of HPP could manifested in a number of CCD patients including our case. This observation raises the problem of whole exome sequencing in patients with overlapped phenotypes.
881 - Trimethylaminuria or Fish Odor Syndrome: First Molecular Study in an Argentinean Cohort
Celia Angaroni, María Fernanda Peralta, and Raquel Dodelson de Kremer
Cemeco. Hospital de Niños de La Santísima Trinidad. Facultad de Ciencias Médicas, Unc, Cordoba, Argentina
Primary genetic Trimethylaminuria (TMA) or Fish Odor Syndrome (FOS) is a disease inherited in an autosomal recessive fashion caused by FMO3 gene mutations that result in loss of function of FMO3 enzyme activity. More than 300 SNPs of the FMO3 have been reported and over 40 of these polymorphisms have been linked to TMA.
882 - Delineation of Clinical and Molecular Phenotype of Aicardi-Goutieres Syndrome in Arab Population
Fuad Al Mutairi
King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
Aicardi-Goutieres syndrome (AGS) is a genetically heterogeneous encephalopathy, patients typically present with early onset encephalopathy. Cerebrospinal fluid showed persistent lymphocytosis and Brain CT showed calcification in the basal ganglia. Patients’ presentation and their family history suggested autosomal recessive and dominant inheritance. We report 23 patients from Middle East descent with AGS, although some patients presented late after initial normal development, but the majority of the cases present early in the neonatal period with subacute severe encephalopathy. Patients exhibit primarily neurological symptoms including, irritability, developmental delay, acquired microcephaly, hypo- or hypert-onia, poor feeding and neonatal seizure. Other systemic symptoms include hepatosplenomegaly and hematological abnormalities and chilblain skin lesions. The course of the disease varies; while some patients die early after severe subacute encephalopathy, in other patients the disease progresses to certain point after which the condition stabilizes. We described the genes mutations related to AGS in our cohort including RNASEH2B, RNASEH2A, RNASEH2C, TREX1, SAMHD1, and IFIH1. The most frequently observed genes associated with AGS were RNASEH2B followed by RNASEH2A. Radiological features of AGS included bilateral basal ganglia calcification that might extend to the deep white matter. Brain MRI might show high signal in the anterior and posterior poles of the lateral ventricles. In severe cases, patients showed frontotemporal leukodystrophy and diffuse cerebral atrophy in MRI. Cerebellar atrophy, brain stem and corpus callosum involvement were observed. This study shed light on genotype, phenotype, and the course of AGS in Arab population.
883 - Cobalamin C Disease Presenting With Neonatal Nephrotic Syndrome: A Case Report
Rahmanifar A1, Moarefian SH2, and Rostami P3
1IEM fellowship, Iranian national Society for Study on Inborn Errors of Metabolism, Iran
2Children Medical Center, Tehran University of Medical Science, Tehran, Iran
884 - Non-Alcoholic Steatohepatitis as a Form of Presentation of Inherited Metabolic Disorders
Margarida Coelho1, Helena Moreira Silva2, Joana Correia1, Anabela Bandeira1, Ermelinda Santos Silva2, and Esmeralda Martins1
1Centro de Referência de Doenças Hereditárias do Metabolismo, Cmin-Chup, Porto, Portugal
2Unidade de Gastroenterologia Pediátrica, Cmin-Chup, Porto, Portugal
885 - Proteome of Plasmodium Falciparum Suffers Oxidative Damage in Erythrocytes With Sickle Trait
Ciro Alvear, Alberto Díaz, Neider Contreras, Jaison Torres, Gregorio Young, Erika Rodríguez, and Darío Méndez
Universidad de Cartagena, Cartagena, Colombia
886 - Understanding the Biology of the “Pterinergic metabolism” in the Brain: Neopterin acts as an Endogenous Cognitive Enhancer
Alexandra Latini1, Karina Ghisoni1, Aderbal Aguiar Jr1, Paulo Alexandre de Oliveira1, Larissa Queiroz1, Carolina Ignácio Geraldo1, Raymond Mongeau2, Laurence Lanfumey2, and Rui Prediger1
1Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
2Inserm, Paris, France
887 - Recurrent Acute Liver Failure in a Family With NBAS Gene Mutation and Successful Liver Transplantation: First Cases From Turkey
Neslihan Mungan1, Dinçer Yildizdaş2, Çiğdem Arikan3, Gökhan Tümgör4, Deniz Kor1, Fatma Derya Bulut1, Berna Seker Yilmaz1, Sebile Kilavuz1
1Çukurova University Div Ped Metabolism, Adana, Turkey
2Çukurova University Div Ped Intensive Care Unit, Adana, Turkey
3Near East University Div Ped Gastroenterology, Lefkoşa, Cyprus
4Çukurova University Div Ped Gastroenterology, Adana, Turkey
Acute liver failure is a currently unresolved and a life-threatening problem in children. Hundreds of causes and a high rate of mortality were reported, however etiological evaluation revealed nothing in about half of cases. The frequently detected causes are inherited metabolic diseases, toxins, drugs, and infections. When the reason of hepatic insufficiency cannot be obtained, it will be difficult to establish an appropriate treatment. Deciding to do a liver transplantation in a child with a nonspecific diagnosis is a difficult and a complex problem. The neuroblastoma amplified sequence (NBAS) gene mutations were related with RALF and SOPH syndromes previously. Also, there are very limited number of reports dealing with only acute liver failure and NBAS gene mutations in the literature. Here, we report two Turkish siblings born from consanguineous parents, that were hospitalized several times with acute attacks of hepatic insufficiency and encephalopathy. The male sibling died at the age of 26 months without a specific diagnosis, but with the suspicion of Wilson disease. Postmortem liver biopsy was compatible with microvesicular fatty degeneration and fibrosis. The clinical picture and the laboratory findings of the other sibling suggested the diagnosis of 3-OH 3 methyl-Co A lyase deficiency, although a mutation was not detected. After consecutive plasmapheresis, at the age of 5 years the female sibling was successfully transplanted from a living donor. 5 years after the transplantation whole exome next generation sequencing revealed a new homozygous c.3602A>C mutation in the NBAS gene. This mutation was also present in heterozygous state in both parents. Our patients did not share the other commonly observed features of systemic forms of NBAS gene mutation; short stature, optic atrophy, cardiomyopathy, gastrointestinal disorders, autoimmune defects, Pelger Huet anomaly, renal and skeletal problems, encephalopathy, and epilepsy. However, they had similar findings of the hepatic phenotype, in which the first attack was usually seen in infancy, triggered with an infection or a vaccination, and mimics the picture of fatty acid oxidation defects. The patient could fully recover from this hepatoencephalopathic attacks or died. Conservative approaches and liver transplantation are the recommended therapeutic options. Our patient is completely well at the 7th year of transplantation. A functional study is under investigation for the new mutation.
888 - Utility of WHOLE EXOME SEQUENCING (WES) in the Diagnosis of Lysosomal Storage Disorders (LSDs)
Alekhya Narravula, Maria Calvo Del Castillo, Claudia Cozma, Sabriana Eichler, Christine Voigt, Oliver Brandau, Omid Paknia, Peter Bauer, and Arndt Rolfs
Centogene Ag, Rostock, Germany
WES is the current test of choice for patients with complex phenotypes and previous uninformative genetic testing. Although LSDs are well-defined disorders, they have overlapping phenotypes and despite biochemical analyses and NGS panels being available, clinicians might opt for WES analysis when unable to arrive at a specific diagnosis. The high cost and large time to diagnosis of step-wise single gene testing or NGS panels; unavailability of enzyme analysis locally; and the possibility of expanding the analysis to a larger set of genes, makes WES a good option for patients with LSDs. In this study, we analyzed the reported WES cases to date with respect to 41 LSD genes, to determine if WES is a good diagnostic tool for LSD cases. The cases were then reviewed to identify those with a confirmed or possible diagnosis.
889 - PGAP3-Related Hyperphosphatasia With Mental Retardation Syndrome: Report of 10 New Patients and a Homozygous Founder Mutation
Maha Zaki1, Mohamed Abdel-Hamid2, Mahmoud Issa3, Ghada Otaify1, Sherif Abdel-Ghafar4, and Hasnaa Elbendary5
1Clinical Genetics Department -National Research Centre, Cairo, Arab Republic of Egypt
2Medical Molecular Genetics Department- National Research Centre, Cairo, Arab Republic of Egypt
3Clinical Genetics Department, National Research Centre, Cairo, Arab Republic of Egypt
4Medical Molecular Genetics Department, National Research Centre, Cairo, Arab Republic of Egypt
5Child Health Department, National Research Centre, Cairo, Arab Republic of Egypt
Hyperphosphatasia with mental retardation syndrome (HPMRS) is caused by recessive mutations in genes involved in the glycosylphosphatidylinsitol pathway, including PGAP3. Herein, we describe 10 patients from 8 Egyptian families presenting with developmental delay, severe intellectual disability, distinct facial dysmorphism and increased alkaline phosphatase. Eight patients had cleft palate, four had postnatal microcephaly and five had seizures. Neuroimaging findings showed thin corpus callosum in 9 patients, mild ventriculomegaly in 3 patients and variable degrees of cerebellar vermis hypoplasia in 4 patients, a finding not previously reported in patients with HPMRS. Additional manifestations included double row teeth, hypogenitalism and congenital heart disease. Biallelic loss of function mutations in the PGAP3 gene were detected in all patients. Nine patients were homozygous for the c.402dupC (p.M135Hfs*28) mutation strongly suggesting a founder effect. On the other hand, one patient had a novel mutation, c.817_820delGACT (p.D273Sfs*37). To our knowledge, this is the largest series of patients with HPMRS from same ethnic group. Our results reinforce the distinct clinical and facial features of PGAP3-related HPMRS which are the clue for targeted genetic testing. Moreover, we present additional unreported clinical and neuro-imaging findings and a novel mutation thus expanding the phenotypic and mutational spectrum of this rare disorder.
890 - Mutation Screening Using Neurogenetics Next Generation Sequencing (NGS) Gene Panel in Patients With Normal Metabolic Profiling
Majed Dasouki, Amal Jabr, Ghadah Aldakheel, Mohamed Abouelhoda, Shazia Subhani, Fahd Elbadaoui, Nada Altassan, and Dorota Monies
King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
891 - IEM unit in a Pediatric Hospital of CABA, 2015-2016 Experience
Marina Szlago1, Claudia Arberas2, and Maria Del Carmen Fernandez3
1Consultorio Ecm, Genetica Medica. Hospital de Niños Ricardo Gutierrez, Caba, Argentina
2Jefa Genetica Medica. Hospital de Niños Ricardo Gutierrez, Caba, Argentina
3Genetica Medica. Hospital de Niños Ricardo Gutierrez, Caba, Argentina
IEM are a heterogeneous group of genetically determined, underdiagnosed pathologies. They often simulate common medical conditions and are not suspected by pediatricians. Their suspicion and early detection allow treatment, medical follow-up and the pertinent genetic advice. The IEM Office was created to cover needs in the context of a High Complexity Pediatric Hospital (HNRG).
892 - Screening ALPL Gene Differences by Next Generation Sequence Techonology in Patients Having Low ALP Levels
Asli İnci, Fatih Ezgü, Burcu Topcu, Bahattin Çiftçi, Ilyas Okur, Gürsel Biberoğlu, and Leyla Tümer
Division of Pediatric Metabolism and Nutrition, Gazi University School of Medicine, Ankara, Turkey
893 - The Added Burden of Common Childhood Presentations in Children With Inborn Errors of Metabolism: A Length of Stay Comparison
Troy Dalkeith1, Andrew Biggin1, Yvonne Zurynski2, and John Christodoulou3
1The Children's Hospital at Westmead. The University of Sydney., Sydney, Australia
2Australian Paediatric Surveillance Unit. The University of Sydney., Sydney, Australia
3Murdoch Childrens Research Institute. University of Melbourne., Melbourne, Australia
Children with inborn errors of metabolism (IEM) can be at greater risk of acute metabolic decompensation as a consequence of common childhood presentations to hospital. The aim of this study was to determine if children with IEMs, admitted for common childhood conditions, had an increased length of stay (LOS) compared to children without IEMs. A retrospective analysis of acute care admissions for children with an underlying IEM to the Children’s Hospital at Westmead was undertaken from 2004 to 2013. This identified 366 admissions for 141 children for common childhood presentations identified according to Diagnosis Related Groups (DRG) coding. This represented 20% of acute care admissions for the IEM cohort. The LOS between the IEM cohort and the state average LOS for each DRG was compared using the Wilcoxon signed rank test. Children with IEMs, having an admission coded by DRG as representing respiratory symptomatology/infections, whooping cough and acute bronchiolitis, viral illness, febrile convulsions and seizures had an increased LOS between 0.2 -1.5 days (P value < .05) greater than the state pediatric reference LOS. These accounted for 55% (202) of total admissions. In contrast, children admitted for bronchitis & asthma, fever of unknown origin, kidney & urinary tract infections, tonsillectomy, adenoidectomy or myringotomy, and esophagitis & gastroenteritis did not have a LOS statistically different to the state based pediatric population for admissions coded with the same DRG. These data show that children with an IEM have an increased LOS for particular childhood presentations. Further studies are required to determine if better metabolic control can improve LOS in this cohort.
894- Perinatal Intracranial Hemorrhage in Ehler Danlos Type 6, Report of 2 Cases
Waseem Fathalla
Mafraq Hospital, Abu Dhabi, United Arab Emirates
895 - Hematological findings in inborn errors of metabolism
Silvia Beatriz Sokn, Consuelo Durand, Joaquin Frabasil, Nora Atanacio, Daniela Gaggioli, Karin Weil, and Andrea Schenone
Laboratorio Chamoles, Buenos Aires, Argentina
896 - The Case That Received Enzyme Replacement Treatment With Congenital Hypophosphatasia
Havva Yazici1, Ebru Canda1, Sema Kalkan Uçar1, Betul Ersoy2, and Mahmut Çoker1
1Division of Pediatric Metabolism and Nutrition, Ege University Faculty of Medicine, Izmir, Turkey
2Division of Pediatric Endocrinology, Celal Bayar University Faculty of Medicine, Izmir, Turkey
Hypophosphatasia is a congenital metabolic disease depending on lack of serum alkaline phosphatase (ALP) activity regarding mutations in the gene encoding isoenzyme not specific for tissue. Mineralization defect in bones and teeth, affected respiratory functions, seizure, hypotony, bone pain, and nephrocalcinosis can be observed. Along with low determined ALP, not low calcium and phosphorus values and increased plasma Pridoxal 5’ Phosphate (PLP) levels are identifiers. Enzyme replacement treatment entered into application. This study aimed to emphasize that patient diagnosed in neonatal period should take part in the definitive diagnosis and share current treatment experience. There was postnatal respiratory distress, soft calvarium, angles in both forearms, seizure in follow-up. In the workups; serum ALP low 10 U/L (N:70 U/L), serum calcium high 13,5 mg/dl (N:9-10.9), serum phosphor normal 4.9 mg/dL (N:3.4-5.9), in the direct graphy, bone structure radiolucent, fracture and callus formations were found. Plasma PLP high 762 µg/L (N:5-50) and urine phosphoethanolamine (PEA) high 1015 µmol/L (N:15-341) and in the ALP gene analysis, p.R184W/p.G288A combined heterozygote mutation was determined. On the 60th day of life, the patient was diagnosed with hypophosphatasia and initiated to have 3 mg/kg/dose asphotase alpha subcutaneous three times a week. Patient had received five dose enzyme replacement treatment and died at home following aspiration. While the disease has different symptoms and distinct clinical forms inherited by autosomal dominant and autosomal recessive ways; congenital hypophosphatasia should take place in the definitive diagnosis in the presence of multiple system findings such as skeleton deformity, spontaneous fractures and along with hypotony, respiratory distress, and seizure. In addition, p.G288A change determined in the patient is a new identified alteration.
897 - Inborn Errors of Metabolism: The Impact in Neonatal and Pediatric Intensive Care
Inês Romão Luz1, Rui Castelo2, Alexandra Dinis3, Gabriela Mimoso4, Lina Ramos5, Luísa Diogo1, and Paula Garcia1
1Reference Centre of Inherited Metabolic Diseases, Hospital Pediátrico, Chuc, Coimbra, Portugal
2Neonatal Intensive Care Unit, Maternidade Dr. Daniel de Matos, Chuc, Coimbra, Portugal
3Pediatric Intensive Care Unit, Hospital Pediátrico, Chuc, Coimbra, Portugal
4Neonatal Intensive Care Unit, Maternidade Bissaya Barreto, Chuc, Coimbra, Portugal
5Genetics Department, Hospital Pediátrico, Chuc, Coimbra, Portugal
898 - A Colombian Reference Center Model in Inborn Errors of Metabolism
Lina Mora1, Luis Alejandro Barrera2, Olga Echeverri1, Lisseth Cabarcas3, Johanna Guevara1, Catalina Forero3, Margarita Pedraza3, Ninna Pulido1, Andrea Ardila1, Diana Gargía3, Geraldine Vargas3, and Lola Restrepo3
1Pontificia Universidad Javeriana, Bogota, Colombia
2Hospital Universitario San Ignacio, Bogotá, Colombia
3Hospital Universitario San Ignacio, Bogota, Colombia
Colombia is a transcontinental country largely situated in the Northwest of South America, with an estimated 49 million people in 2017, Colombia is the third-most populous country in Latin America, after Brazil and Mexico. In 2016, the National Administrative Department of Statistics (DANE) reported that 28.0% of the population were living below the poverty line, of which 8.5% in “extreme poverty.
Since 1993 a new health system was introduced, this new system has widened population coverage by the social and health security system from 21% in 1993 to 96% in 2012, however just since 2010 rare diseases are recognized as being of special interest and rules are adopted to guarantee social protection by the Colombian State to the population suffering from orphan diseases and their caregivers. Right now, the discussion is around the newborn screening and reference centers. The Hospital Universitario San Ignacio, which was recently ranked among Latin America’s twenty best hospitals by the influential business journal América Economía, is a 4th level university hospital in Bogotá, Colombia. It is located on the campus of the Pontificia Universidad Javeriana and is home to this school’s faculties of Medicine, Nursing, and Dentistry. As part of the hospital, is the Inborn Errors of Metabolism Clinic (CEIM), which is a reference center for rare diseases since 2012, the group of the CEIM was organized around two institutes that are currently integrated into the San Ignacio Hospital in terms of services: The Institute of Human Genetics and Inborn Errors of Metabolism. Each one has more than thirty years of experience in the study of these diseases. They were joined by specialists from different disciplines who have managed patients with metabolic diseases and who are convinced that a specialized clinic is the best way to provide the comprehensive service that these patients require. Each year the clinic receives patients from different parts of the country, and even nearby countries; as a university hospital receives undergraduate students, medical doctors with previous training in pediatrics, medical genetics or child neurology and dietitians. We want to describe all the activities developed in inborn errors of metabolism by a Colombian reference center.
899 - ERNDIM Diagnostic Proficiency Testing is an Important Tool in Determining Quality of Laboratory Diagnosis in a Wide Range of Inborn Errors of Metabolism
Brian Fowler1, Petr Chrastina2, Joanne Croft3, Viktor Kozich2, George Ruijter4, and Christine Saban5
1University Children’s Hospital, Basel/Zürich, Switzerland
2Institute of Inherited Metabolic Diseases, Prague, Czech Republic
3Children’s Hospital, Sheffield, United Kingdom
4Erasmus Medical Center, Rotterdam, Netherlands
5Service Maladies Héréditaires Du Métabolisme, Bron-Lyon, France
ERNDIM (www.erndim.org) aims to improve the quality of diagnosis and monitoring in patients with inborn errors of metabolism (IEM) through quality assurance programs and educational activities. Diagnostic proficiency testing schemes focus on the ability of laboratories to identify and interpret abnormalities in natural urine samples reflecting a wide range of IEMs. During the past decade 264 samples from 83 different conditions, were distributed to up to 105 laboratories mainly from Europe but also worldwide, by five centers in the Czech Republic, France, Netherlands, Switzerland, and United Kingdom and latterly from a central provider (CSCQ). Six samples a year, one common to all centers, were distributed together with clinical information. Laboratories choose and perform the tests (limited amount of urine) needed to reach a diagnosis using analysis of one or more of amino acids, organic acids, mucopolysaccharides, oligosaccharides and purines and pyrimidines. Performance is evaluated according to scores for analysis and interpretation and lack of critical error, in line with harmonization with other genetic disciplines. Diagnostic proficiency, based on analytical findings and interpretation, ranged widely from below 50% for extremely challenging samples to 100% for more straightforward ones. Taken together, diagnostic proficiency (average % of total points possible for all participating laboratories within all schemes for all samples) was: amino acid disorders, n disorders/samples = 27/71, range 26-100, mean 78%; organic acid disorders, n = 33/89, range 14-100, mean 87%; mucopolysaccharide disorders, n = 5/34, range 67-93, mean 81%; oligosaccharide disorders, n = 6/19, range 10-99, mean 65%; purine/pyrimidine disorders, n = 8/22, range 12-93, mean 69%; miscellaneous disorders, n = 6/7, range 17-91, mean 63%; no IEM n = 21, range 65-95, mean 85%. When the sample was re-distributed in a subsequent survey from the same center, performance improved in 21 cases (average 15%) with no improvement seen in 13. Although difficult to interpret this suggests improvement in performance. In conclusion, ERNDIM diagnostic proficiency testing is a valuable activity which can: inform accreditation; help to assess individual laboratory performance; and identify methodological and technical challenges contributing to improved diagnostic approaches. Further, clinicians must be aware that laboratory testing for IEM is fraught with difficulties and results need to be viewed with caution.
900 - Continuous Age - and Sex-Corrected Reference Ranges of Plasma Alkaline Phosphatase (ALP)
Yngve Thomas Bliksrud and Lars Mørkrid
Dep. Med. Biochemistry, Oslo University Hosptial, Oslo, Norway
901 - Clinical Profile of Patients With Inborn Errors of Metabolism Treated at the Pediatric Clinic of Metalobic Diseases of the Federal University of Rio de Janeiro
Julia Albuquerque, Helio Rocha, Monica Moretzsohn, Alessandra Braga, Tamires Camargo, Viviane Santos, Nathalia Fernandes, Lilian Licurgo, Roberta Zahra, Laura Ohana, Maria Carolina Porto, Maria da Silva, and Alexandre Woolf
UFRJ, Rio de Janeiro, RJ, Brazil
902 - Diagnostic Investigation of Inborn Errors of Metabolism in Patients With Intellectual Disabilities in the State of Bahia
Paula Correa1, Aruanã Fontes2, Milena Magalhães3, Polyanna Oliveira4, Daniel Silva4, Daniel Jesus5, Emília Leão1, Beatriz Silva6, Kiyoko Abe-Sandes7, and Angelina Acosta8
1Medical Genetics Service, Professor Edgard Santos University Hospital, Federal University of Bahia, Salvador, BA, Brazil
2Post-Graduation in Medicine in Health of The Federal University of Bahia, Salvador, BA, Brazil
3Post-Graduation in Medicine in Health of The Federal University of Bahia, Salvador, Bahia, Brazil, Salvador, BA, Brazil
4Gonçalo Moniz Research Center, Oswaldo Cruz Foundation, Salvador, BA, Brazil
51 Medical Genetics Service, Professor Edgard Santos University Hospital, Federal University of Bahia, Salvador, BA, Brazil
6Faculty of Medicine, Federal University of Bahia, Salvador, BA, Brazil
7Laboratory of Immunology and Molecular Biology, Federal University of Bahia, Salvador, BA, Brazil
83 Department of Pediatrics, Faculty of Medicine, Federal University of Bahia, Salvador, BA, Brazil
903 - Laboratory Protocol for Genetic Diseases in Individuals With Autism Spectrum Disorder Associated With Intellectual Disability
Paula Correa1, Milena Magalhães2, Jessica Fernandes2, Beatriz Silva3, Milena Ponde4, Ana Paola Robatto5, Stella Benitez5, Emília Leão6, and Angelina Acosta5
1Medical Genetics Service, Professor Edgard Santos University Hospital, Federal University of Bahia, Salvador, BA, Brazil
2Post-Graduation in Medicine in Health of The Federal University of Bahia, Salvador, BA, Brazil
3Faculty of Medicine, Federal University of Bahia, Salvador, BA, Brazil
4Interdisciplinary Laboratory of Autism Research of The Bahian School of Medicine, Salvador, BA, Brazil
5Faculty of Medicine, Department of Pediatrics, Federal University of Bahia, Salvador, BA, Brazil
6Department of Life Sciences, State University of Bahia, Salvador, BA, Brazil
904 - Inherited Duplication Disrupting the Gene MYH10: A Case Characterized by Microcephaly, Severe Developmental Delay, and Dysmorphic Features
Elisabetta Salvatici1, Graziella Cefalo1, Sabrina Paci1, Cristina Gervasini2, Valentina Sottili1, Marina Crosa1, Giovanna Sironi1, Sara Osimani1, and Giuseppe Banderali1
1Department of Clinical Paediatric, San Paolo Hospital, University of Milan, Milano, Italy
2Department of Medical Genetics, San Paolo Hospital, University of Milan, Milano, Italy
We describe the clinical and genetic characteristics of a child with a duplication disrupting the gene MYH10. The patient, third child, born at term, female of healthy nonconsanguineous parents. The pregnancy was characterized by mother smoking and anhydramnios. The parents coming for low-income, low-education, with the father working as a waiter. Birth weight was 2900 g (10th centile), length 48 cm (10th centile), and head circumference 32 cm (<3 rd centile). At the age of 11 months, she was hospitalized to investigate microcephaly, dysmorphic features (fine hair, tip narrow nose with flattened nasal root and wings, thin upper lip, and edentulous), severe developmental delay (bubbling, grasping objects, sitting, rolling, and crawling still not acquired) and axial hypertonia. Metabolic screening, EEG, audiometric examination, echocardiogram and abdominal ultrasound were normal. Brain MRI showed brain atrophy, mainly of the frontal lobes. In consideration of developmental delay and facial dysmorphism, CGH-Array was performed. This showed a paternal 73 kb duplication between nucleotides 8,386,920 and 8,460,142, in the p13.1 band of chromosome 17, involving the gene MYH10; which encodes the non-muscle myosin heavy chain IIB critical for heart and brain development. Loss of MYH10 function in mice results in embryonic lethality, hydrocephalus and neuronal migration defects but the cognitive and behavioral phenotype of heterozygous mice has not been reported yet. Heterozygous de novo mutations in association with human neurological disease have been previously described in only 3 cases, characterized by loss of function of the protein: a nonsense mutation, a missense mutation (c.838C>T, p.Arg280Cys) and a nonsense truncating variant p.E908X (c.2722G > T), all having microcephaly and severe developmental delay with marked cerebral and cerebellar atrophy complicated by ex-vacuo hydrocephalus or basal ganglia and thalami involvement. Neither human MYH10 gain of function nor duplications, similar to our case, have yet been described in literature or reported in the Database of Genomic Variation and Phenotype in Humans using Ensemble Resources. Nonetheless, considering the function of the gene and the pathogenic role of its mutation, we can hypothesize a possible intrafamilial expression variability seen the patient’s clinical phenotype and its genotype. More cases need to be reported to establish with certainty this pathogenic correlation.
905 - Use of Proton Nuclear Magnetic Resonance (H1-NMR) for Diagnosis of Inborn errors of Metabolism
Ninna Pulido1, Olga Echeverri2, Johana Guevara2, and Carlos Alméciga-Díaz2
1Pontificia Universidad Javeriana, Bogotá, Colombia
2Instituto de Errores Innatos Del Metabolismo, Puj, Bogotá, Colombia
906 - Effect of pH on an Oxalate Oxidase Method for Plasma Oxalate
Hayley Sharrod-Cole, Adam Gerrard, and Mary Anne Preece
Birmingham Women’s and Children’s Nhs Foundation Trust, Birmingham, United Kingdom
907 - Inborn Errors of Metabolism Presenting With Non-Immune Hydrops Fetalis: Novel Molecular Findings and Useful Clues for the Diagnosis Approach
Carolina Moreno1, Carlos Steiner2, Marcella Baptista2, Cristiane Gomes3, Albina Altemani3, Arthur Tavares3, Maira Burin4, Roberto Giugliani4, Ana Carolina Brusius-Facchin4, Sandra Leistner-Segal4, Kristiane Michelin4, Rejane Kessler4, Roseline Froissart5, and Denise Cavalcanti1
1Programa de Genética Perinatal, Departamento Genética Médica, Faculdade de Ciências Médicas, Unicamp, Campinas, SP, Brazil
2Departamento de Genética Médica, Faculdade de Ciências Médicas, Unicamp, Campinas, SP, Brazil
3Departamento de Anatomia-Patológica, Faculdade de Ciências Médicas, Unicamp, Campinas, SP, Brazil
4Serviço de Genética Médica, Hospital de Clínicas de Porto Alegre, Ufrgs, Porto Alegre, RS, Brazil
5Laboratoire Des Maladies Héréditaires Du Métabolisme, Centre de Biologie Est, Groupement Hospitalier, Lyon, France
Some inborn errors of metabolism (IEM) manifest prenatally with non-immune hydrops fetalis (NIHF). The frequency of IEM in hydropic fetus is usually underestimated due to inadequate investigation approach. The aim of this presentation is to describe eight Brazilian newborns with NIHF caused by different IEM, emphasizing some findings that can contribute to the diagnosis during the NIHF evaluation, and showing novel molecular variants. The diagnosis was based on biochemical and/or molecular analysis, and the metabolic investigation started after the exclusion of the main etiologies of NIHF. We identified six patients with lysosomal storage disorders (LSD)—gangliosidosis GM1 [3], infantile sialic acid storage disease (ISSD) [1], galactosialidosis [1], MPS VII [1]; and two cases of congenital glycosylation defect (CDG)—PMM2-CDG. The familial history analysis showed two families with previous child with hydrops of “unknown” etiology due to incomplete investigation. The placenta evaluation was performed in four cases of LSD (gangliosidosis GM1 [2], ISSD [1] and galactosialidosis [1]) and it was observed vacuolization of trophoblast and/or stromal cells leading to hypothesis of LSD in all of them. The babygram of seven infants showed findings suggestive of LSD (osteopenia, coarse trabeculation, metaphyseal fraying and periosteal cloaking) in the infant with ISSD, and subtler signs in the baby with galactosialidosis. The two infants with PMM2-CDG presenting with delayed pubis ossification. Molecular tests detected 10 confirmed or likely pathogenic variants, including four previously not described. A novel variant in PMM2 (c.97C>T; p.Gly33Ter) was confirmed in two not related families, suggesting a common ancestral and a possible founder effect. A uncommon variant in PMM2 (c.193G>T; p.Asp65Tyr) was identified in one family, reinforcing the hypothesis of Iberian origin of this variant. Finally, the variant c.1498A>G (p.Thr500Ala) in GLB1, classically associated with Morquio B, was related to gangliosidosis GM1 for the first time. The results highlight the importance to include a systematic approach to investigate NIHF, including radiological and placental examination, because they may provide some clues related to metabolic etiology. The study expands the molecular data about the diseases and give new information about genotype-phenotype correlation related to GLB1.
908 - Episodic Vomiting as a Manifestation of Glycerol Kinase Deficiency
María Pacheco1, Rosana Filtrin1, Hernán Eiroa2, and Mariana Morales1
1Hospital Público Materno Infantil de Salta, Salta, Argentina
2Hospital Nacional de Pediatría J. P. Garrahan, Buenos Aires, Argentina
Isolated glycerol kinase deficiency (GKD) is a very rare X-linked disorder of glycerol metabolism characterized biochemically by elevated plasma and urine glycerol levels, and clinically by variable neurometabolic manifestations, depending on the age of onset, infantile, juvenile, and adult. As a result, complex GKD usually presents as an infantile syndrome commonly including vomiting, failure to thrive and acidosis, which may progress to lethargy, seizures, psychomotor retardation and coma. Isolated GKD may also present as a childhood metabolic crisis with developmental decompensation or be discovered as a relatively benign asymptomatic form in adulthood. Both types of isolated GKD are thought to result from different genetic mutations affecting the activity or regulation of GK. Symptoms depend on the size of deletion.
909 - Lactose Intolerance as an Inborn Error of Metabolism
Henrique Ajudarte Pinheiro dos Santos Nassif
INSS, Governador Valadares, MG, Brazil
Lactose intolerance is an enzymatic defect, or the absence of, resulting in inability to digest it. In some perspective should be seen as a public health problem. Children and even adults might develop allergies, neurologic and cognitive symptoms. These could end in absenteeism in school and work. Reposition of the lactase enzyme by public health system should be considered in poor populations. This paper will review some articles about lactose intolerance, public health and inborn error of metabolism.
910 - Autosomal Recessive Infantile Osteopetrosis: Three Cases With Three Novel Mutations
Berna Seker Yilmaz1, Deniz Kor1, Fatma Derya Bulut1, Sebile Kilavuz1, Ibrahim Bayram2, Göksel Leblebisatan3, Ilgen Şaşmaz3, and Neslihan Mungan1
1Div Ped Metabolism, Çukurova University, Adana, Turkey
2Div Ped Oncology, Çukurova University, Adana, Turkey
3Div Ped Hematology, Çukurova University, Adana, Turkey
911 - Urinary Amino Acids: Should We Screen Our Requests?
Caroline Hart and Maureen Cleary
Great Ormond Street Hospital, London, United Kingdom
912 - 10 Years of Rare Inborn Errors of Metabolism and Rare Metabolic Disorders Research Funding in the European Union
Egle Simelyte, Elmar Nimmesgern, and Irene Norstedt
Directorate Health, Directorate-General for Research and Innovation, European Commission, Brussels, Belgium
913 - Thinking of an Inborn Error of Metabolism in Manaus-AM
Vania Prazeres. Bárbara Campos Perini, Bianka da Silva Paiva, Clarisse Diógenes Pinheiro Paiva, Fernanda Nakanishi Murakami, Juliana Veras de Mesquita, and Ricardo da Cunha Araújo
Universidade Federal do Amazonas, Manaus, AM, Brazil
914 - A Multi-Specialty Autism Clinic
Stephen Kahler, Marie Tippett, John Slattery, and Richard Frye
University of Arkansas for Medical Sciences, Little Rock, AR, USA
Clinics devoted to autism spectrum disorders (ASDs) are usually devoted to diagnosis and behavioral interventions, or the application of genetic diagnostic methods to patients with ASDs. We established an autism multi-specialty clinic in 2008 to evaluate, manage, and understand the biomedical aspects of the ASDs. The diagnosis of autism is done by others, using standard methods. The genetic evaluation of patients with ASDs typically includes chromosome microarray, karyotype, fragile X analysis, and a panel of autism-related genes. Biochemical evaluation can include routine chemistry analysis, plasma amino acids, acylcarnitines, urine organic acids, creatine metabolites and nucleotides. A specific “cause” might be found in 20%-40% of patients. These tests do not address the numerous co-morbidities found in patients with autism, and how addressing them might ameliorate the autism symptoms. Our clinic addresses the common experience of intestinal dysfunction in children with autism—gastroesophageal reflux, abnormal stooling, bowel inflammation, and food intolerance. Dysbiosis is being investigated. Significant food and intestinal issues are present in perhaps a third of our current patients. Disturbed sleep and increased irritability are common. All these aspects are treatable. The clinic core includes a metabolic geneticist, neurologist, gastroenterologist, dietician, and coordinator. An immunology component is being added because of the discovery of autoantibodies to brain components (Cunningham panel), and connections between mitochondrial and immune dysfunction. There is no obvious relationship between genetic and metabolic “causes” of autism, and the presence or absence of intestinal, mitochondrial, or immunologic dysfunction. The clinic is affiliated with research projects devoted to mitochondrial dysfunction, oxidative stress, folic acid metabolism, and cerebral folate deficiency, and immune dysfunction. The clinic meets one full day weekly. Follow-up visits and phone calls are done separately. In a typical recent year there were 1216 outpatient visits. Roughly 5% of the patients are admitted for overnight EEG, often accompanied by brain MRI and lumbar puncture. Patients come from the USA and abroad. The current waiting list is more than a year, emphasizing the desire and need for comprehensive assessment and treatment.
915 - High Frequency of Duplication of 24 bp in Indigenous of Northern Brazil
Luiz Carlos Santana-Da-Silva and Brenda Silva
Laboratory of Inborn Errors of Metabolism, Federal University of Pará, Belém, PA, Brazil
916 - WWOX-Related Encephalopathy Mimicking GLUT-1 Deficiency: Expanding the Phenotype
Thereza Cavalcanti, Rayana Maia, Marina Estima Neiva Nunes, Ana Beatriz Gonçalves, Carolina Funayama, and Charles Lourenço
HCRP, Usp Ribeirao Preto, Ribeirao Preto, SP, Brazil
917 - Exome Sequencing for Understanding the Genetics of Complex Diseases
Lina Johanna Moreno Giraldo, Jose Maria Satizabal Soto, and Adalberto Sanchez
Universidad Del Valle, Cali, Colombia
There are thousands of known associations between genetic variants and complex human phenotypes, and the rate of novel discoveries is increasing. One of those is absence of ulna and fibula with severe limb deficiency. It is a rare autosomal recessive disorder characterized by severe malformations of upper and lower limbs with severe lyhypoplastic pelvis and abnormal genitalia. The disorder is believed to represent a defect of dorso-ventral patterning and outgrowth of limbs and Charcot-Marie-Tooth (CMT) disease type 4C. It is caused by homozygous or compound heterozygous mutation in the SH3TC2 gene; affected individuals had peripheral motor and sensory neuropathy and reduced Median nerve, consistent with a demyelinating process. A 5-year-old male patient, mestizo race, with clinical diagnosis of arthrogryposis, congenital hip dislocation, bilateral varus-equine-foot, right tibiae torsion, tendon transposition, multiple genital plasty, resection of face tumor pilomaxitroma, pectum excavatum, obesity, learning disturbance, normal brain magnetic resonance, normal karyotype, normal metabolic studies is reported. Exome sequencing was performed for this patient on the iIIumina platform. 2 pathogenic variants on WNT7A gene located at chromosome 3 (position 13860881, Clin Var rs387907231), and SH3TC2 gene located at chromosome 5 (position 148407326, ClinVar rs80338925) both reported as pathogenic were identified. According to the signs and symptoms of the patient, and using the base of Data GeneMANIA and evaluation on networks and expression, co-expression, it is found an interaction between the 2 genes associated with the structure of the extracellular matrix, metabolic processes of collagen, growth factor, and skeletal system development brain development. Intersecting the compendium of identified genetic associations with maps of regulatory activity across the human exome has revealed that phenotype-associated variants are highly enriched in candidate regulatory elements.
918 - Evolution and Correlation of Number of Published Papers About Inborn Errors Of Metabolism in PubMed, Scielo.org, and Scielo.br From 20th TO 21st Century
Ian Feitosa
Ufpe/Famed/Dmc & Ufrgs/Degen/Ppgbm, Recife, PE, Brazil
Number of papers about Inborn Errors of Metabolism (IEM) in medical databases is widely variable and has increased over time, just like the proportion of Brazilian papers on this issue. This work describes the evolution and correlation of the number of paper in PubMed, Scielo.org and Scielo.br databases between 20th and 21st centuries. Using INBORN+ERRORS+METABOLISM as keywords, 2667 papers have been retrieved in PubMed, 107 in Scielo.org and 23 in Scielo.br. Comparing the number of published papers on IEM, no difference between PubMed and Scielo.br have been observed using chi square test (neither looking at 21st X 20th century nor comparing 2001-Today X All time before 2010, P = .093 and P = .500, respectively). However, number of papers in PubMed was significantly higher than that in Scielo.org (P < .001) considering both centuries (all time), likely as a result of a “dilution” of Brazilian papers (accounting for 21.5% of the total amount of papers in Scielo.org). The results may reflect a relevant proportion of Brazilian papers (from Brazilian journals or indexed in Scielo.br) in the total of papers in Scielo.org, as well as that the evolution and increase in papers on IEM in Scielo.br correlates and resembles that of PubMed.
919 - Carnitine and TMAO Metabolism in Children With Various Inborn Errors Of Metabolism Receiving Oral or Intravenous Carnitine
Carolina Galarreta, Sarah Choi, Jon Gangoiti, Bruce Barshop
UCSD, La Jolla, CA, USA
L-Carnitine is used in the treatment of several inborn errors of metabolism (IEM). Trimethylamine-N-oxide (TMAO) is a gut derived carnitine metabolite which has recently been associated with cardiovascular risk, thus raising concerns about the long-term safety of carnitine supplementation. We aim to study the metabolism of carnitine and its derivatives including TMAO in children with various inborn errors of metabolism receiving oral L-carnitine or intravenous carnitine.